Basic Information
| Provider Information | |||||||||
| NPI: | 1720495146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PAIN CENTER OF ARIZONA, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEORIA DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 9401 W THUNDERBIRD RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235168252 | ||||||||
| FaxNumber: | 6235168253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDESTY | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMIN OPERATIONS | ||||||||
| 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 | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.