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General NPI Number Information
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NPI Number | 1457622763
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Entity Type | Organization
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Legal Business Name | PANACEA BRAIN AND SPINE, LLC
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Dates
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Enumeration Date | 01/18/2012
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Last Update Date | 06/29/2020
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Provider Practice Location Address
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Address Line | 72 LAKE HAVASU AVE S STE 102
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-0857
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Country | US
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Telephone | 928-453-2211
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Fax | 928-453-2213
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Provider Business Mailing Address
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Address Line | 72 LAKE HAVASU AVE S STE 102
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-0857
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Country | US
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Telephone | 928-453-2211
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Fax | 928-453-2219
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHAD HARTLEY
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Credential | MD
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Telephone | 720-883-1593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 46605
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License Number State | AZ
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