Provider Demographics
NPI:1770911299
Name:PERMIAN BACK TREATMENT CENTER, PA
Entity type:Organization
Organization Name:PERMIAN BACK TREATMENT CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:432-332-2858
Mailing Address - Street 1:1030 N GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-3149
Mailing Address - Country:US
Mailing Address - Phone:432-332-3388
Mailing Address - Fax:432-332-3390
Practice Address - Street 1:1030 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3149
Practice Address - Country:US
Practice Address - Phone:432-332-3388
Practice Address - Fax:432-332-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5710111N00000X
TXK4046207LP2900X
TX208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty