Provider Demographics
NPI:1023604931
Name:ADVANCED SPINE AND PAIN SURGERY CENTERS LLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND PAIN SURGERY CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRET
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-573-0210
Mailing Address - Street 1:2525 W GREENWAY RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2101
Practice Address - Country:US
Practice Address - Phone:480-573-0210
Practice Address - Fax:480-573-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical