Healthcare Provider Details

I. General information

NPI: 1306601760
Provider Name (Legal Business Name): NOVASPINE PAIN INSTITUTE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 N 67TH AVE STE 300
GLENDALE AZ
85308-3657
US

IV. Provider business mailing address

PO BOX 5068
SUN CITY WEST AZ
85376-5068
US

V. Phone/Fax

Practice location:
  • Phone: 623-777-4747
  • Fax:
Mailing address:
  • Phone: 623-777-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER SPENCER
Title or Position: PRACTICE ADMIN
Credential:
Phone: 623-777-4747