Healthcare Provider Details

I. General information

NPI: 1700173473
Provider Name (Legal Business Name): UTAH SPINE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 1815
OGDEN UT
84403-3271
US

IV. Provider business mailing address

4403 HARRISON BLVD STE 1815
OGDEN UT
84403-3271
US

V. Phone/Fax

Practice location:
  • Phone: 801-732-5950
  • Fax: 801-732-5988
Mailing address:
  • Phone: 801-732-5950
  • Fax: 801-732-5988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number1835611205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1765801205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2626351205
License Number StateUT

VIII. Authorized Official

Name: TROY FULLER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 801-732-5950