Provider Demographics
NPI:1518381060
Name:DVM PAIN GROUP PLLC
Entity Type:Organization
Organization Name:DVM PAIN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-510-3567
Mailing Address - Street 1:18205 N 51ST AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1490
Mailing Address - Country:US
Mailing Address - Phone:602-354-4370
Mailing Address - Fax:602-354-4370
Practice Address - Street 1:18205 N 51ST AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1490
Practice Address - Country:US
Practice Address - Phone:602-354-4370
Practice Address - Fax:602-354-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3870363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty