Provider Demographics
NPI:1073962593
Name:TEXAS PAIN PRACTICE LLC
Entity Type:Organization
Organization Name:TEXAS PAIN PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDELFATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-241-0997
Mailing Address - Street 1:1712 PIONEER AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1712 PIONEER AVE STE 500
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4406
Practice Address - Country:US
Practice Address - Phone:915-241-0997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP9994284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital