Provider Demographics
NPI:1235327917
Name:POWAR PAIN CLINIC
Entity Type:Organization
Organization Name:POWAR PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:POWAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-453-0696
Mailing Address - Street 1:1840 MESQUITE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-453-8500
Mailing Address - Fax:928-453-3660
Practice Address - Street 1:1775 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6549
Practice Address - Country:US
Practice Address - Phone:928-453-0696
Practice Address - Fax:928-453-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24843261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ21472Medicare PIN