1013008895 NPI number — FREEDOM PAIN CARE LLC

Table of content: (NPI 1013008895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013008895 NPI number — FREEDOM PAIN CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREEDOM PAIN CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013008895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7451 CHAPEL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76116-7090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-294-7444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
918 N DAVIS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76012-3226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-860-9933
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
OLLIS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-294-7444

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  228850 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 228850 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00C18V . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".