Healthcare Provider Details

I. General information

NPI: 1336544964
Provider Name (Legal Business Name): PHOENIX PREMIERE PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 N 16TH ST
PHOENIX AZ
85016-1706
US

IV. Provider business mailing address

6351 PRESTON RD STE 295
FRISCO TX
75034-6422
US

V. Phone/Fax

Practice location:
  • Phone: 602-253-4271
  • Fax: 214-872-3387
Mailing address:
  • Phone: 214-872-3381
  • Fax: 214-872-3387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOSC 4400
License Number StateAZ

VIII. Authorized Official

Name: LYNN DUGGER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 214-872-3381