Provider Demographics
NPI:1407276793
Name:ADDISON HEADACHE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ADDISON HEADACHE ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-234-4740
Mailing Address - Street 1:PO BOX 674183
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4183
Mailing Address - Country:US
Mailing Address - Phone:972-479-1115
Mailing Address - Fax:972-346-8015
Practice Address - Street 1:17051 DALLAS PKWY
Practice Address - Street 2:STE 100
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7101
Practice Address - Country:US
Practice Address - Phone:469-916-0521
Practice Address - Fax:972-231-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center