1871263178 NPI number — SOUTHWEST SPINE AND PAIN CARE SPECIALISTS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871263178 NPI number — SOUTHWEST SPINE AND PAIN CARE SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST SPINE AND PAIN CARE SPECIALISTS, LLC
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:
1871263178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 912042
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84791-2042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-215-0230
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2891 E MALL DRIVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
SAINT GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-688-1665
Provider Business Practice Location Address Fax Number:
435-619-8634
Provider Enumeration Date:
09/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
OBRAY
Authorized Official First Name:
JON
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
435-215-0230

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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