Provider Demographics
NPI:1982124582
Name:PHOENIX PAIN TREATMENT CENTERS, PLLC
Entity Type:Organization
Organization Name:PHOENIX PAIN TREATMENT CENTERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVER
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PENNY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-362-4747
Mailing Address - Street 1:9140 W THOMAS RD STE B-106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3378
Mailing Address - Country:US
Mailing Address - Phone:602-362-4747
Mailing Address - Fax:623-463-1111
Practice Address - Street 1:9140 W THOMAS RD STE B-106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3378
Practice Address - Country:US
Practice Address - Phone:602-362-4747
Practice Address - Fax:623-463-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC8621208VP0014X
261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265672067OtherNPPES
1669427233OtherNPPES
1174614622OtherNPPES
1881646289OtherNPPES
1205874922OtherNPPES
1023080744OtherNPPES