1891320644 NPI number — SOUTHWEST SPINE AND PAIN CARE SPECIALISTS, LLC

Table of content: (NPI 1891320644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891320644 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:
SOUTHWEST SPINE AND PAIN CENTER
Provider Other Organization Name Type Code:
3
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:
1891320644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2023
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:
435-986-7092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 N 200 E STE 2A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84770-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-688-7246
Provider Business Practice Location Address Fax Number:
435-688-1363
Provider Enumeration Date:
03/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDEN
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
435-656-2424

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NS0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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