Healthcare Provider Details

I. General information

NPI: 1275389306
Provider Name (Legal Business Name): SOUTHWEST PRIME CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 E GARNET AVE
MESA AZ
85204-6013
US

IV. Provider business mailing address

1747 E GARNET AVE
MESA AZ
85204-6013
US

V. Phone/Fax

Practice location:
  • Phone: 480-388-7585
  • Fax:
Mailing address:
  • Phone: 480-388-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN TYLER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 480-388-7585