Provider Demographics
NPI:1689122103
Name:GRAYSON INTERVENTIONAL PAIN CENTER
Entity Type:Organization
Organization Name:GRAYSON INTERVENTIONAL PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 674057
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4057
Mailing Address - Country:US
Mailing Address - Phone:972-916-0521
Mailing Address - Fax:972-234-0212
Practice Address - Street 1:1600 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8112
Practice Address - Country:US
Practice Address - Phone:469-916-0521
Practice Address - Fax:972-234-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain