Provider Demographics
NPI:1174185649
Name:PISA ASC HOLDCO LLC
Entity Type:Organization
Organization Name:PISA ASC HOLDCO LLC
Other - Org Name:PAIN INSTITUTE OF SOUTHERN ARIZONA PROCEDURE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-318-6035
Mailing Address - Street 1:4881 E GRANT ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-318-6035
Mailing Address - Fax:520-795-9953
Practice Address - Street 1:4741 E CAMP LOWELL DRIVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-318-6035
Practice Address - Fax:520-795-9953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ003149Medicaid