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General NPI Number Information
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NPI Number | 1265791255
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Entity Type | Organization
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Legal Business Name | PHOENIX PAIN RELIEF CENTERS, PA
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Dates
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Enumeration Date | 05/10/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 1000 GALLOPING HILL RD SUITE 106
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City | UNION
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State | NJ
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Zip | 07083-7989
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Country | US
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Telephone | 908-378-5028
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Fax | 908-378-5796
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Provider Business Mailing Address
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Address Line | 1000 GALLOPING HILL RD SUITE 106
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City | UNION
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State | NJ
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Zip | 07083-7989
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Country | US
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Telephone | 908-378-5028
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Fax | 908-378-5796
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Authorized Official
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Title or Position | DIRECTOR
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Name | RUDOLPH WILLIS
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Credential | MD
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Telephone | 908-378-5028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MA04275000
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License Number State | NJ
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