MEDICARE: SKYLINE PAIN CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	260615	UT

General Provider Information

NPI Number	:	1053308452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYLINE PAIN CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 9519
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84409-0519
Country	:	US
Telephone Number	:	801-476-4448
Fax Number	:	801-476-4449

Provider Business Practice Location Address
First Line	:	5315 ADAMS AVE PKWY
Second Line	:	SUITE A
City	:	OGDEN
State	:	UT
Zip	:	84405-4766
Country	:	US
Telephone Number	:	801-476-4448
Fax Number	:	801-476-4449

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAHAN IMANI
Credential	:	MD
Telephone Number	:	801-476-4448

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	12/23/2009

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Directions to “SKYLINE PAIN CLINIC ” Practice Location

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