Healthcare Provider Details

I. General information

NPI: 1346694676
Provider Name (Legal Business Name): PAIN MANAGEMENT AND WELLNESS INSTITUTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 N TATUM BLVD SUITE 102-302
PHOENIX AZ
85028-6055
US

IV. Provider business mailing address

10810 N TATUM BLVD SUITE 102-302
PHOENIX AZ
85028-6055
US

V. Phone/Fax

Practice location:
  • Phone: 602-740-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DALLIN JENKINS
Title or Position: MANAGER
Credential:
Phone: 480-265-0890