Provider Demographics
NPI:1568909836
Name:GLACIER PEAK PAIN CARE PLLC
Entity Type:Organization
Organization Name:GLACIER PEAK PAIN CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-413-3130
Mailing Address - Street 1:1407 N 2000 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8562
Mailing Address - Country:US
Mailing Address - Phone:385-333-7123
Mailing Address - Fax:
Practice Address - Street 1:1407 N 2000 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8562
Practice Address - Country:US
Practice Address - Phone:385-333-7123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9777824-1205208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty