Provider Demographics
NPI:1801273800
Name:MANCHESTER INTERVENTIONAL PAIN CENTER LLC
Entity type:Organization
Organization Name:MANCHESTER INTERVENTIONAL PAIN CENTER LLC
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:972-788-7500
Mailing Address - Street 1:PO BOX 674032
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-4032
Mailing Address - Country:US
Mailing Address - Phone:972-479-1115
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty