Provider Demographics
NPI:1902654197
Name:GERIATRIC AND PAIN HEALTH LLC
Entity Type:Organization
Organization Name:GERIATRIC AND PAIN HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOMTILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MWEI
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTIONER
Authorized Official - Phone:734-961-2979
Mailing Address - Street 1:7531 E BILLINGS ST UNIT 147
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-7592
Mailing Address - Country:US
Mailing Address - Phone:734-961-2979
Mailing Address - Fax:
Practice Address - Street 1:1910 S STAPLEY DR STE 120
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6676
Practice Address - Country:US
Practice Address - Phone:734-961-2979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain