Provider Demographics
NPI:1730197286
Name:DALLAS SPINE CARE PA
Entity type:Organization
Organization Name:DALLAS SPINE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-688-0078
Mailing Address - Street 1:7600 JOHN W CARPENTER FWY
Mailing Address - Street 2:PMB #8
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4827
Mailing Address - Country:US
Mailing Address - Phone:214-688-0078
Mailing Address - Fax:
Practice Address - Street 1:9080 HARRY HINES BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-1720
Practice Address - Country:US
Practice Address - Phone:214-688-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC1011363A00000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0013BYMedicare PIN