Provider Demographics
NPI:1497129274
Name:CENTRAL TEXAS PAIN INSTITUTE, PLLC
Entity Type:Organization
Organization Name:CENTRAL TEXAS PAIN INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-485-7200
Mailing Address - Street 1:PO BOX 208361
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8361
Mailing Address - Country:US
Mailing Address - Phone:512-485-7208
Mailing Address - Fax:844-364-8678
Practice Address - Street 1:3401 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-2694
Practice Address - Country:US
Practice Address - Phone:855-876-7246
Practice Address - Fax:855-277-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7566332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R03WOtherMEDICARE PTAN