Provider Demographics
NPI:1487863353
Name:MOUNT OGDEN PAIN MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNT OGDEN PAIN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CINDIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DODENBIER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:435-755-9174
Mailing Address - Street 1:4520 S 900 W # 324
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-7155
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:286 N GATEWAY DR
Practice Address - Street 2:STE A
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9733
Practice Address - Country:US
Practice Address - Phone:435-755-9174
Practice Address - Fax:435-755-9148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5306448-1205208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty