Healthcare Provider Details

I. General information

NPI: 1750064465
Provider Name (Legal Business Name): INNOVATIVE PAIN AND WELLNESS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

IV. Provider business mailing address

18511 N SCOTTSDALE RD STE 202
SCOTTSDALE AZ
85255-9694
US

V. Phone/Fax

Practice location:
  • Phone: 480-467-2273
  • Fax:
Mailing address:
  • Phone: 480-306-7242
  • Fax: 480-306-6246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL KARL OCONNOR
Title or Position: OWNER
Credential:
Phone: 480-306-7242