Healthcare Provider Details

I. General information

NPI: 1811811656
Provider Name (Legal Business Name): DESERT SPINE AND PAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21001 N TATUM BLVD STE 78-1640
PHOENIX AZ
85050-5244
US

IV. Provider business mailing address

21001 N TATUM BLVD STE 78-1640
PHOENIX AZ
85050-5244
US

V. Phone/Fax

Practice location:
  • Phone: 602-566-9500
  • Fax: 602-357-4904
Mailing address:
  • Phone: 602-566-9500
  • Fax: 602-357-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BENN WILLCOX
Title or Position: OWNER / EMPLOYEE
Credential:
Phone: 561-701-1771