Healthcare Provider Details

I. General information

NPI: 1639951577
Provider Name (Legal Business Name): ADVANCED SPINE AND PAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W THOMAS RD STE 204
PHOENIX AZ
85013-4425
US

IV. Provider business mailing address

2525 W GREENWAY RD STE 125
PHOENIX AZ
85023-4226
US

V. Phone/Fax

Practice location:
  • Phone: 480-573-0130
  • Fax: 480-573-0131
Mailing address:
  • Phone: 480-573-0130
  • Fax: 480-573-0131

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 Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JARRETT MICHAEL LEATHEM
Title or Position: OWNER
Credential:
Phone: 860-670-2412