Healthcare Provider Details

I. General information

NPI: 1144076829
Provider Name (Legal Business Name): CANYON PAIN AND SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4566 E INVERNESS AVE STE 108
MESA AZ
85206-4633
US

IV. Provider business mailing address

4566 E INVERNESS AVE STE 108
MESA AZ
85206-4633
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 TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

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