Provider Demographics
NPI:1639180797
Name:GRAPEVINE IMAGING & PAIN MANAGEMENT CENTER LLC
Entity Type:Organization
Organization Name:GRAPEVINE IMAGING & PAIN MANAGEMENT CENTER LLC
Other - Org Name:ECLIPSE IMAGING PAIN MANAGEMENT CENTER-GRAPEVINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-479-0800
Mailing Address - Street 1:2401 IRA E WOODS
Mailing Address - Street 2:#600
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8631
Mailing Address - Country:US
Mailing Address - Phone:817-488-9991
Mailing Address - Fax:817-488-9992
Practice Address - Street 1:2401 IRA E WOODS
Practice Address - Street 2:#600
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8631
Practice Address - Country:US
Practice Address - Phone:817-488-9991
Practice Address - Fax:817-488-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR255792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX376985800OtherDOL
TX9676331OtherCIGNA
TX0119DCOtherBCBS
TX303769901Medicaid
TX9676331OtherCIGNA