Provider Demographics
NPI:1043234685
Name:INTERWEST COMPREHENSIVE PAIN CENTER
Entity Type:Organization
Organization Name:INTERWEST COMPREHENSIVE PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-753-1600
Mailing Address - Street 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:2380 N 400 E
Practice Address - Street 2:STE A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1749
Practice Address - Country:US
Practice Address - Phone:435-713-9681
Practice Address - Fax:435-753-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6006178-1205207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty