Healthcare Provider Details

I. General information

NPI: 1366049025
Provider Name (Legal Business Name): CACTUS PAIN RELIEF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20255 N LAKE PLEASANT RD STE 102
PEORIA AZ
85382-9747
US

IV. Provider business mailing address

20255 N LAKE PLEASANT RD STE 102
PEORIA AZ
85382-9747
US

V. Phone/Fax

Practice location:
  • Phone: 623-225-7154
  • Fax: 623-376-8225
Mailing address:
  • Phone: 623-225-7154
  • Fax: 623-376-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDON KULP
Title or Position: OWNER
Credential:
Phone: 623-225-7154