Provider Demographics
NPI:1073807939
Name:INNOVATION PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:INNOVATION PAIN MANAGEMENT, LLC
Other - Org Name:INNOVATION PAIN MANAGMENT, LLC-AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-899-2053
Mailing Address - Street 1:1988 W 930 N
Mailing Address - Street 2:SUITE B
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-4131
Mailing Address - Country:US
Mailing Address - Phone:801-899-2053
Mailing Address - Fax:801-492-7615
Practice Address - Street 1:1988 W 930 N
Practice Address - Street 2:SUITE B
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4131
Practice Address - Country:US
Practice Address - Phone:801-899-2053
Practice Address - Fax:801-492-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical