Provider Demographics
NPI:1568009801
Name:FLAGSTAFF PAIN AND TREATMENT CENTER
Entity Type:Organization
Organization Name:FLAGSTAFF PAIN AND TREATMENT CENTER
Other - Org Name:FLAGSTAFF PAIN AND TREATMENT CENTER, L.L.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NANCE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:602-903-0360
Mailing Address - Street 1:11811 N TATUM BLVD STE 3031
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1621
Mailing Address - Country:US
Mailing Address - Phone:602-903-0360
Mailing Address - Fax:
Practice Address - Street 1:823 N SAN FRANCISCO ST STE A
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3265
Practice Address - Country:US
Practice Address - Phone:602-903-0360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical