Healthcare Provider Details

I. General information

NPI: 1902077100
Provider Name (Legal Business Name): CENTER FOR PAIN TREATMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S 6TH ST
COTTONWOOD AZ
86326-4237
US

IV. Provider business mailing address

55 S 6TH ST
COTTONWOOD AZ
86326-4237
US

V. Phone/Fax

Practice location:
  • Phone: 928-634-5118
  • Fax: 928-634-8522
Mailing address:
  • Phone: 928-634-5118
  • Fax: 928-634-8522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4555
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4555
License Number StateAZ

VIII. Authorized Official

Name: MR. PAUL E QUINTERO
Title or Position: CO-OWNER
Credential: VICE PRESIDENT
Phone: 928-634-5118