Healthcare Provider Details

I. General information

NPI: 1588291330
Provider Name (Legal Business Name): LASER PAIN AWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 E MCKELLIPS RD STE 102
MESA AZ
85215-2862
US

IV. Provider business mailing address

6025 E MCKELLIPS RD STE 102
MESA AZ
85215-2862
US

V. Phone/Fax

Practice location:
  • Phone: 480-370-0527
  • Fax:
Mailing address:
  • Phone: 480-370-0527
  • Fax: 480-534-5927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1013
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerACUPUNCTURE

VIII. Authorized Official

Name: JASON CALDWELL
Title or Position: OWNER
Credential: DOM
Phone: 480-370-0527