Provider Demographics
NPI:1497326615
Name:AZ PAIN MEDICINE CLINIC, LLC.
Entity Type:Organization
Organization Name:AZ PAIN MEDICINE CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-8800
Mailing Address - Street 1:8805 N 23RD AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4116
Mailing Address - Country:US
Mailing Address - Phone:602-368-8800
Mailing Address - Fax:602-368-8801
Practice Address - Street 1:8805 N 23RD AVE STE 160
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4116
Practice Address - Country:US
Practice Address - Phone:602-368-8800
Practice Address - Fax:602-368-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty