Provider Demographics
NPI:1578176087
Name:PG PRO LLC
Entity Type:Organization
Organization Name:PG PRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-930-4018
Mailing Address - Street 1:PO BOX 11180
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0020
Mailing Address - Country:US
Mailing Address - Phone:480-930-4018
Mailing Address - Fax:480-930-4018
Practice Address - Street 1:4715 STATESMEN DR STE AB
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-5642
Practice Address - Country:US
Practice Address - Phone:317-643-5865
Practice Address - Fax:317-436-7212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty