Provider Demographics
NPI:1851552400
Name:DESERT VALLEY ADVANCED PAIN MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:DESERT VALLEY ADVANCED PAIN MANAGEMENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:DIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-863-3924
Mailing Address - Street 1:11024 N 28TH DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4377
Mailing Address - Country:US
Mailing Address - Phone:602-863-3924
Mailing Address - Fax:602-863-3926
Practice Address - Street 1:11024 N 28TH DR
Practice Address - Street 2:SUITE 160
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4377
Practice Address - Country:US
Practice Address - Phone:602-863-3924
Practice Address - Fax:602-863-3926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ127383OtherMEDICARE PTAN