Provider Demographics
NPI:1245694728
Name:PAIN & INJURY CLINIC OF UTAH
Entity type:Organization
Organization Name:PAIN & INJURY CLINIC OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDIE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:YOUNGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-475-1910
Mailing Address - Street 1:1186 E. 4600 S.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-475-1910
Mailing Address - Fax:801-475-4245
Practice Address - Street 1:1186 E. 4600 S.
Practice Address - Street 2:SUITE 220
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-475-1910
Practice Address - Fax:801-475-4245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111340-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty