Provider Demographics
NPI:1437532850
Name:WILSHIRE INTERVENTIONAL PAIN CENTER LLC
Entity Type:Organization
Organization Name:WILSHIRE INTERVENTIONAL PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NETWORK DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-215-7410
Mailing Address - Street 1:PO BOX 674326
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4326
Mailing Address - Country:US
Mailing Address - Phone:512-467-1100
Mailing Address - Fax:
Practice Address - Street 1:901 W 38TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1163
Practice Address - Country:US
Practice Address - Phone:512-501-2110
Practice Address - Fax:512-371-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty