=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659786002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE PAIN CONSULTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2014
-----------------------------------------------------
Last Update Date | 10/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34665 N 45TH ST
-----------------------------------------------------
City | CAVE CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85331-4728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-239-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 72628
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85050-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-239-7090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | COLA GREEN
-----------------------------------------------------
Credential | CANPC
-----------------------------------------------------
Telephone | 602-308-7827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------