Provider Demographics
NPI:1528764131
Name:ADVANCED SPINE AND PAIN LLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRETT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEATHEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-670-2412
Mailing Address - Street 1:PO BOX 29901 DEPT ID 976
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-0901
Mailing Address - Country:US
Mailing Address - Phone:480-573-0130
Mailing Address - Fax:
Practice Address - Street 1:9949 W BELL RD STE 100
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-1200
Practice Address - Country:US
Practice Address - Phone:480-573-0130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty