Healthcare Provider Details

I. General information

NPI: 1255795134
Provider Name (Legal Business Name): PAIN MANAGEMENT PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4541 S 700 E SUITE 100
MURRAY UT
84107-4118
US

IV. Provider business mailing address

4541 S 700 E SUITE 100
MURRAY UT
84107-4118
US

V. Phone/Fax

Practice location:
  • Phone: 801-713-1560
  • Fax: 801-713-1562
Mailing address:
  • Phone: 801-713-1560
  • Fax: 801-713-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE WILCOX
Title or Position: OWNER
Credential:
Phone: 801-713-1560