Healthcare Provider Details

I. General information

NPI: 1962180844
Provider Name (Legal Business Name): CANYON PAIN AND SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S HIGLEY RD STE 102
GILBERT AZ
85296-4798
US

IV. Provider business mailing address

1425 S HIGLEY RD STE 102
GILBERT AZ
85296-4798
US

V. Phone/Fax

Practice location:
  • Phone: 480-561-5000
  • Fax: 480-984-4066
Mailing address:
  • Phone: 480-561-5000
  • Fax: 480-984-4066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KIRK GEORGE BOWDEN
Title or Position: OWNER
Credential:
Phone: 480-889-0255