Provider Demographics
NPI:1013248715
Name:CLEBURNE INTERVENTIONAL PAIN PROCEDURE CENTER LLC
Entity Type:Organization
Organization Name:CLEBURNE INTERVENTIONAL PAIN PROCEDURE 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 678439
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8439
Mailing Address - Country:US
Mailing Address - Phone:972-234-4740
Mailing Address - Fax:817-645-5944
Practice Address - Street 1:121 S WESTMEADOW DR STE C
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4590
Practice Address - Country:US
Practice Address - Phone:972-234-4740
Practice Address - Fax:972-231-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain