Provider Demographics
NPI:1508193186
Name:AZ PAIN MANAGEMENT & PHYSICAL THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:AZ PAIN MANAGEMENT & PHYSICAL THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ODESSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-567-7678
Mailing Address - Street 1:PO BOX 984
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20757-0984
Mailing Address - Country:US
Mailing Address - Phone:301-567-7678
Mailing Address - Fax:301-567-3643
Practice Address - Street 1:6188 OXON HILL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3113
Practice Address - Country:US
Practice Address - Phone:301-567-7678
Practice Address - Fax:301-567-3643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty