Provider Demographics
NPI:1316114663
Name:SOUTHWEST COMPREHENSIVE PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:SOUTHWEST COMPREHENSIVE PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR AND LLC MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-780-1563
Mailing Address - Street 1:1749 W BRAMBLE BERRY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8044
Mailing Address - Country:US
Mailing Address - Phone:623-780-1563
Mailing Address - Fax:
Practice Address - Street 1:1749 W BRAMBLE BERRY LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-8044
Practice Address - Country:US
Practice Address - Phone:623-780-1563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32912261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBB8831580OtherDEA
AZBB8831580OtherDEA