Provider Demographics
NPI:1073959714
Name:WASATCH SPORTS, SPINE & PAIN TREATMENT CENTER PLLC
Entity Type:Organization
Organization Name:WASATCH SPORTS, SPINE & PAIN TREATMENT CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-768-2755
Mailing Address - Street 1:680 E MAIN ST
Mailing Address - Street 2:202
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2241
Mailing Address - Country:US
Mailing Address - Phone:801-768-2755
Mailing Address - Fax:801-768-2658
Practice Address - Street 1:680 E MAIN ST
Practice Address - Street 2:202
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2241
Practice Address - Country:US
Practice Address - Phone:801-768-2755
Practice Address - Fax:801-768-2658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty