Healthcare Provider Details

I. General information

NPI: 1568009801
Provider Name (Legal Business Name): FLAGSTAFF PAIN AND TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 N SAN FRANCISCO ST STE A
FLAGSTAFF AZ
86001-3265
US

IV. Provider business mailing address

11811 N TATUM BLVD STE 3031
PHOENIX AZ
85028-1621
US

V. Phone/Fax

Practice location:
  • Phone: 602-903-0360
  • Fax:
Mailing address:
  • Phone: 602-903-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN NANCE
Title or Position: MANAGER
Credential: RN
Phone: 602-903-0360