Provider Demographics
NPI:1922372713
Name:KELLER INTERVENTIONAL PAIN CENTER, LLC
Entity Type:Organization
Organization Name:KELLER INTERVENTIONAL PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-362-6909
Mailing Address - Street 1:PO BOX 674191
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4191
Mailing Address - Country:US
Mailing Address - Phone:817-571-2607
Mailing Address - Fax:
Practice Address - Street 1:1305 AIRPORT FWY
Practice Address - Street 2:SUITE 103
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6605
Practice Address - Country:US
Practice Address - Phone:817-571-2607
Practice Address - Fax:817-571-0897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain