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General NPI Number Information
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NPI Number | 1346848090
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Entity Type | Organization
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Legal Business Name | REVITALIZE PAIN AND SPINE LLC
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Dates
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Enumeration Date | 10/14/2020
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Last Update Date | 10/14/2020
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Provider Practice Location Address
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Address Line | 4838 E BASELINE RD STE 110
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City | MESA
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State | AZ
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Zip | 85206-4674
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Country | US
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Telephone | 480-210-2641
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Fax | 480-210-2642
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Provider Business Mailing Address
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Address Line | 4838 E BASELINE RD STE 110
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City | MESA
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State | AZ
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Zip | 85206-4674
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Country | US
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Telephone | 480-210-2641
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Fax | 480-210-2642
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Authorized Official
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Title or Position | DIRECTOR
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Name | AMY WILLIAMS
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Credential |
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Telephone | 480-969-4040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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