Provider Demographics
NPI:1659805976
Name:ADVANCED PAIN AND HEADACHE MEDICAL CLINIC
Entity Type:Organization
Organization Name:ADVANCED PAIN AND HEADACHE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IBETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-530-0003
Mailing Address - Street 1:PO BOX 980101
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4151 SOUTHWEST FWY STE 720
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7308
Practice Address - Country:US
Practice Address - Phone:713-530-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization