Healthcare Provider Details

I. General information

NPI: 1134582570
Provider Name (Legal Business Name): SOUTHWEST SPINE AND PAIN CARE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 1400 N SUITE 135
LOGAN UT
84341-2534
US

IV. Provider business mailing address

652 S MEDICAL CENTER DR SUITE 110
ST GEORGE UT
84790-7049
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-2424
  • Fax: 535-787-8149
Mailing address:
  • Phone: 435-656-2424
  • Fax: 535-787-8149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JON OBTAY
Title or Position: PRESIDENT
Credential: MD
Phone: 435-656-2424