Healthcare Provider Details

I. General information

NPI: 1013975333
Provider Name (Legal Business Name): SONORAN SPINE CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 W RIO SALADO PKWY STE 105
TEMPE AZ
85281-2892
US

IV. Provider business mailing address

1255 W RIO SALADO PKWY STE 107
TEMPE AZ
85281-2892
US

V. Phone/Fax

Practice location:
  • Phone: 602-443-6480
  • Fax: 602-443-6499
Mailing address:
  • Phone: 480-962-0071
  • Fax: 480-962-0590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN DYLO
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-962-0071