Healthcare Provider Details

I. General information

NPI: 1265044119
Provider Name (Legal Business Name): PRESTIGE SPINE INTERVENTIONAL PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 UNITED DR STE 340
CONWAY AR
72032-7826
US

IV. Provider business mailing address

650 UNITED DR STE 340
CONWAY AR
72032-7826
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6791
  • Fax:
Mailing address:
  • Phone: 501-993-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: APRIL JOHNSON
Title or Position: MEMBER
Credential: MEMBER
Phone: 501-993-8300