Provider Demographics
NPI:1811159437
Name:PAINCARE OF ARIZONA II, LLC
Entity type:Organization
Organization Name:PAINCARE OF ARIZONA II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SKY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-488-4558
Mailing Address - Street 1:14175 W INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE B-4-517
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8407
Mailing Address - Country:US
Mailing Address - Phone:602-488-4558
Mailing Address - Fax:
Practice Address - Street 1:14175 W INDIAN SCHOOL RD
Practice Address - Street 2:SUITE B-4-517
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8407
Practice Address - Country:US
Practice Address - Phone:602-488-4558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4249261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4249OtherOTC