1366183584 NPI number — TIMBER MEDICAL AND PAIN CENTER PLLC

Table of content: (NPI 1366183584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366183584 NPI number — TIMBER MEDICAL AND PAIN CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMBER MEDICAL AND PAIN CENTER PLLC
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:
1366183584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6019 RIM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKESIDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85929-5092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-632-2807
Provider Business Mailing Address Fax Number:
928-532-8599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 S WHITE MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOW LOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85901-7306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-532-7599
Provider Business Practice Location Address Fax Number:
928-532-8599
Provider Enumeration Date:
04/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PACE
Authorized Official First Name:
JASON
Authorized Official Middle Name:
FRANK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-632-2807

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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