1154780237 NPI number — THE PAIN CENTER OF ARIZONA, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154780237 NPI number — THE PAIN CENTER OF ARIZONA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PAIN CENTER OF ARIZONA, PC
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:
6
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:
1154780237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5281 N 99TH AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85305-3105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-516-8252
Provider Business Mailing Address Fax Number:
623-691-8502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20333 N 19TH AVE STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85027-3627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-516-8252
Provider Business Practice Location Address Fax Number:
623-516-8253
Provider Enumeration Date:
02/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HARDESTY
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ADMIN OPS
Authorized Official Telephone Number:
623-516-8252

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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