Healthcare Provider Details

I. General information

NPI: 1538667795
Provider Name (Legal Business Name): CENTER FOR WELLNESS AND PAIN CARE OF WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3426 BROADWAY STE 101
EVERETT WA
98201-5098
US

IV. Provider business mailing address

311 N BUFFALO DR STE A
LAS VEGAS NV
89145-0375
US

V. Phone/Fax

Practice location:
  • Phone: 702-476-9700
  • Fax:
Mailing address:
  • Phone: 702-476-9700
  • Fax: 702-476-9138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number15175
License Number StateNV

VIII. Authorized Official

Name: NEVILLE CAMPBELL
Title or Position: MD
Credential: MD
Phone: 702-476-9700