Provider Demographics
NPI:1376821587
Name:CANYON RIDGE PAIN AND SPINE PC
Entity Type:Organization
Organization Name:CANYON RIDGE PAIN AND SPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:KEM
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-205-4116
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7667
Mailing Address - Country:US
Mailing Address - Phone:801-205-4116
Mailing Address - Fax:435-986-9368
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 460
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-205-4116
Practice Address - Fax:435-986-9368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6955001-1205208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty