1508193186 NPI number — AZ PAIN MANAGEMENT & PHYSICAL THERAPY CENTER, LLC

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 1508193186 NPI number — AZ PAIN MANAGEMENT & PHYSICAL THERAPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZ PAIN MANAGEMENT & PHYSICAL THERAPY CENTER, 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:
1508193186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE HILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20757-0984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-567-7678
Provider Business Mailing Address Fax Number:
301-567-3643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6188 OXON HILL RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
OXON HILL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20745-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-567-7678
Provider Business Practice Location Address Fax Number:
301-567-3643
Provider Enumeration Date:
11/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CRUZ
Authorized Official First Name:
ODESSA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
301-567-7678

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  18557 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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