Healthcare Provider Details

I. General information

NPI: 1043771645
Provider Name (Legal Business Name): BEAR RIVER SPINE CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 1400 N STE 115
LOGAN UT
84341-2691
US

IV. Provider business mailing address

630 E 1400 N STE 115
LOGAN UT
84341-2691
US

V. Phone/Fax

Practice location:
  • Phone: 435-799-7955
  • Fax:
Mailing address:
  • Phone: 435-799-7955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN VERNON
Title or Position: CEO
Credential: MD
Phone: 435-799-7955