Basic Information
| Provider Information | |||||||||
| NPI: | 1649518101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PAIN CENTER OF ARIZONA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5281 N 99TH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853053105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235168252 | ||||||||
| FaxNumber: | 6235168253 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 E CAMELBACK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235168252 | ||||||||
| FaxNumber: | 6235168253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/10/2014 | ||||||||
| NPIReactivationDate: | 07/08/2014 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDESTY | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMIN OP | ||||||||
| AuthorizedOfficialTelephone: | 6232416101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE PAIN CENTER OF ARIZONA, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 29038 | AZ | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.