Healthcare Provider Details

I. General information

NPI: 1114536992
Provider Name (Legal Business Name): ELVIAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22601 N 19TH AVE STE 100
PHOENIX AZ
85027-1324
US

IV. Provider business mailing address

22601 N 19TH AVE STE 100
PHOENIX AZ
85027-1324
US

V. Phone/Fax

Practice location:
  • Phone: 623-231-2443
  • Fax:
Mailing address:
  • Phone: 623-231-2443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM WUOLLET
Title or Position: OWNER, MD
Credential:
Phone: 623-231-2443