Basic Information
| Provider Information | |||||||||
| NPI: | 1255840914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED PAIN AND SPINE OTC ,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13203 N 103RD AVE STE H5 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237774747 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13203 N 103RD AVE STE H5 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237774747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | CLIFFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6237774747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 1235342775 | 01 | AZ | INDIVIDUAL NPI | OTHER |