Provider Demographics
NPI:1295045854
Name:SUMMIT AVENUE PAIN CENTER, LLC
Entity Type:Organization
Organization Name:SUMMIT AVENUE PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-362-6909
Mailing Address - Street 1:PO BOX 674210
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4210
Mailing Address - Country:US
Mailing Address - Phone:972-234-4740
Mailing Address - Fax:972-231-7095
Practice Address - Street 1:1201 SUMMIT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4413
Practice Address - Country:US
Practice Address - Phone:972-234-4740
Practice Address - Fax:972-231-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain