Provider Demographics
NPI:1053308452
Name:SKYLINE PAIN CLINIC
Entity Type:Organization
Organization Name:SKYLINE PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-476-4448
Mailing Address - Street 1:PO BOX 9519
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84409-0519
Mailing Address - Country:US
Mailing Address - Phone:801-476-4448
Mailing Address - Fax:801-476-4449
Practice Address - Street 1:5315 ADAMS AVE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4766
Practice Address - Country:US
Practice Address - Phone:801-476-4448
Practice Address - Fax:801-476-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT260615208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid