Provider Demographics
NPI:1508368465
Name:SOUTHWEST SPINE AND PAIN CARE SPECIALISTS LLC
Entity Type:Organization
Organization Name:SOUTHWEST SPINE AND PAIN CARE SPECIALISTS LLC
Other - Org Name:SOUTHWEST HEALING AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PFATENHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-215-0230
Mailing Address - Street 1:652 S MEDICAL CENTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7077
Mailing Address - Country:US
Mailing Address - Phone:435-215-0230
Mailing Address - Fax:435-251-3735
Practice Address - Street 1:1085 S BLUFF ST STE 200
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5245
Practice Address - Country:US
Practice Address - Phone:435-218-7778
Practice Address - Fax:435-275-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health