Healthcare Provider Details

I. General information

NPI: 1033359419
Provider Name (Legal Business Name): SAG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 07/21/2022
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 W ROOSEVELT ST
PHOENIX AZ
85009-3404
US

IV. Provider business mailing address

4220 N 20TH AVE
PHOENIX AZ
85015-5124
US

V. Phone/Fax

Practice location:
  • Phone: 602-889-9401
  • Fax: 602-269-7772
Mailing address:
  • Phone: 602-889-9401
  • Fax: 602-889-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROSE MATA-ESPINOZA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 602-687-8219