Provider Demographics
NPI:1952853152
Name:DALLAS INTERVENTIONAL PAIN PLLC
Entity Type:Organization
Organization Name:DALLAS INTERVENTIONAL PAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-422-0641
Mailing Address - Street 1:15110 DALLAS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-4601
Mailing Address - Country:US
Mailing Address - Phone:972-349-1333
Mailing Address - Fax:
Practice Address - Street 1:5316 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4821
Practice Address - Country:US
Practice Address - Phone:972-349-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9070208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty