Provider Demographics
NPI:1639951577
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: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 1:2525 W GREENWAY RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4226
Mailing Address - Country:US
Mailing Address - Phone:480-573-0130
Mailing Address - Fax:480-573-0131
Practice Address - Street 1:333 W THOMAS RD STE 204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4425
Practice Address - Country:US
Practice Address - Phone:480-573-0130
Practice Address - Fax:480-573-0131
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED SPINE AND PAIN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty