1609173293 NPI number — EAST VALLEY PAIN PHYSICIANS, 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 1609173293 NPI number — EAST VALLEY PAIN PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VALLEY PAIN PHYSICIANS, 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:
1609173293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15262 N 75TH AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-4763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-486-1510
Provider Business Mailing Address Fax Number:
623-486-1529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18610 E RITTENHOUSE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85142-4503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-486-1510
Provider Business Practice Location Address Fax Number:
623-486-1529
Provider Enumeration Date:
02/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GOLLIHAR
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
623-486-1510

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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