Provider Demographics
NPI:1942580162
Name:ADVANCED PAIN CLINIC
Entity Type:Organization
Organization Name:ADVANCED PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAWNA
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOULDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-409-2044
Mailing Address - Street 1:6028 S RIDGELINE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6914
Mailing Address - Country:US
Mailing Address - Phone:801-409-2044
Mailing Address - Fax:801-475-4948
Practice Address - Street 1:6028 S RIDGELINE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6914
Practice Address - Country:US
Practice Address - Phone:801-409-2044
Practice Address - Fax:801-475-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6414842-12042081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty