Provider Demographics
NPI:1932689403
Name:GREAT BASIN PAIN & WELLNESS LLC
Entity Type:Organization
Organization Name:GREAT BASIN PAIN & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA,FNP-C,APRN
Authorized Official - Phone:801-372-5785
Mailing Address - Street 1:PO BOX 2001
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2001
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:1775 BROWNING WAY STE 102
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8338
Practice Address - Country:US
Practice Address - Phone:775-299-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty