Provider Demographics
NPI:1629679923
Name:ADVANCED SPINE AND PAIN LLC
Entity Type:Organization
Organization Name:ADVANCED SPINE AND PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRETT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEATHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-670-2412
Mailing Address - Street 1:4566 E INVERNESS AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4634
Mailing Address - Country:US
Mailing Address - Phone:480-640-0513
Mailing Address - Fax:
Practice Address - Street 1:4566 E INVERNESS AVE STE 205
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4634
Practice Address - Country:US
Practice Address - Phone:480-640-0513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-03
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty