Provider Demographics
NPI:1528402039
Name:NEUROPATHY AND PAIN CENTRE OF PRESCOTT LLC
Entity Type:Organization
Organization Name:NEUROPATHY AND PAIN CENTRE OF PRESCOTT LLC
Other - Org Name:ENERGIE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-458-7343
Mailing Address - Street 1:1000 WILLOW CREEK RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1645
Mailing Address - Country:US
Mailing Address - Phone:928-458-7343
Mailing Address - Fax:
Practice Address - Street 1:1000 WILLOW CREEK RD
Practice Address - Street 2:SUITE D
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-458-7343
Practice Address - Fax:928-257-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3075207R00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816045Medicaid
AZ816045Medicaid