Provider Demographics
NPI:1265044119
Name:PRESTIGE SPINE INTERVENTIONAL PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:PRESTIGE SPINE INTERVENTIONAL PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MEMBER
Authorized Official - Phone:501-993-8300
Mailing Address - Street 1:650 UNITED DR STE 340
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-7826
Mailing Address - Country:US
Mailing Address - Phone:501-993-8300
Mailing Address - Fax:
Practice Address - Street 1:650 UNITED DR STE 340
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7826
Practice Address - Country:US
Practice Address - Phone:501-358-6791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty