Provider Demographics
NPI:1164013900
Name:CANYON PAIN AND WELLNESS PLLC
Entity Type:Organization
Organization Name:CANYON PAIN AND WELLNESS PLLC
Other - Org Name:AZ INFUSION CENTER PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAWERU
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:602-325-2020
Mailing Address - Street 1:6120 W BELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3780
Mailing Address - Country:US
Mailing Address - Phone:602-472-2157
Mailing Address - Fax:
Practice Address - Street 1:6120 W BELL RD STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3780
Practice Address - Country:US
Practice Address - Phone:602-472-2157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical