Healthcare Provider Details

I. General information

NPI: 1528953791
Provider Name (Legal Business Name): PAIN MANAGEMENT PI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 S 900 E STE 1001515
MIDVALE UT
84047-1709
US

IV. Provider business mailing address

1515 E FORT UNION BLVD
COTTONWOOD HEIGHTS UT
84121-2855
US

V. Phone/Fax

Practice location:
  • Phone: 801-755-7181
  • Fax:
Mailing address:
  • Phone: 801-755-7181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: PEDRO LIRA
Title or Position: HEALTHCARE ADMINISTRATOR
Credential:
Phone: 801-755-7181