1699209221 NPI number — MOUNTAIN SPINE PC

Table of content: (NPI 1699209221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699209221 NPI number — MOUNTAIN SPINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN SPINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699209221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 E 11400 S # 245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84070-6705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
385-414-7080
Provider Business Mailing Address Fax Number:
385-325-0004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11613 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-9456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-414-7080
Provider Business Practice Location Address Fax Number:
385-325-0004
Provider Enumeration Date:
04/20/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SNOOK
Authorized Official First Name:
GARY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MEDICAL DOCTOR/ OWNER
Authorized Official Telephone Number:
385-414-7080

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  5688087-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)