Healthcare Provider Details

I. General information

NPI: 1073807939
Provider Name (Legal Business Name): INNOVATION PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1988 W 930 N SUITE B
PLEASANT GROVE UT
84062-4131
US

IV. Provider business mailing address

1988 W 930 N SUITE B
PLEASANT GROVE UT
84062-4131
US

V. Phone/Fax

Practice location:
  • Phone: 801-899-2053
  • Fax: 801-492-7615
Mailing address:
  • Phone: 801-899-2053
  • Fax: 801-492-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateUT

VIII. Authorized Official

Name: NATHAN DEE MILLER
Title or Position: MANAGING MEMBER
Credential: D.C.
Phone: 801-899-2053