Provider Demographics
NPI:1376864462
Name:PINETOP-LAKESIDE INTEGRATIVE & PHYSICAL MEDICINE,LLC
Entity Type:Organization
Organization Name:PINETOP-LAKESIDE INTEGRATIVE & PHYSICAL MEDICINE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-358-1648
Mailing Address - Street 1:1628 REED LN
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6983
Mailing Address - Country:US
Mailing Address - Phone:928-358-1648
Mailing Address - Fax:
Practice Address - Street 1:1628 REED LN
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6983
Practice Address - Country:US
Practice Address - Phone:928-358-1648
Practice Address - Fax:928-368-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-13
Last Update Date:2010-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34673208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty