Healthcare Provider Details

I. General information

NPI: 1992205512
Provider Name (Legal Business Name): PEAK WELLNESS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20950 N TATUM BLVD STE 100
PHOENIX AZ
85050-4204
US

IV. Provider business mailing address

20950 N TATUM BLVD STE 100
PHOENIX AZ
85050-4204
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-7246
  • Fax:
Mailing address:
  • Phone: 480-222-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL15479R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberD01889748
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number50572
License Number StateAZ

VIII. Authorized Official

Name: DEANNA M CONNER
Title or Position: OFFICE
Credential:
Phone: 623-238-8424