Provider Demographics
NPI:1093128316
Name:THE PAIN CENTER OF ARIZONA, PC
Entity Type:Organization
Organization Name:THE PAIN CENTER OF ARIZONA, PC
Other - Org Name:DV 106
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIJALVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-241-6152
Mailing Address - Street 1:5281 N 99TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3105
Mailing Address - Country:US
Mailing Address - Phone:623-516-8252
Mailing Address - Fax:623-516-8253
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:623-516-8252
Practice Address - Fax:623-241-6021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE PAIN CENTER OF ARIZONA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-04
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ71338Medicare PIN