Provider Demographics
NPI:1265791255
Name:PHOENIX PAIN RELIEF CENTERS, PA
Entity type:Organization
Organization Name:PHOENIX PAIN RELIEF CENTERS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-378-5028
Mailing Address - Street 1:1000 GALLOPING HILL RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7989
Mailing Address - Country:US
Mailing Address - Phone:908-378-5028
Mailing Address - Fax:908-378-5796
Practice Address - Street 1:1000 GALLOPING HILL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7989
Practice Address - Country:US
Practice Address - Phone:908-378-5028
Practice Address - Fax:908-378-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04275000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty