Healthcare Provider Details

I. General information

NPI: 1487863353
Provider Name (Legal Business Name): MOUNT OGDEN PAIN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 N GATEWAY DR STE A
PROVIDENCE UT
84332-9733
US

IV. Provider business mailing address

4520 S 900 W # 324
RIVERDALE UT
84405-7155
US

V. Phone/Fax

Practice location:
  • Phone: 435-755-9174
  • Fax: 435-755-9148
Mailing address:
  • Phone: 435-753-1600
  • Fax: 435-753-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number5306448-1205
License Number StateUT

VIII. Authorized Official

Name: CINDIE G DODENBIER
Title or Position: PRESIDENT
Credential: APRN
Phone: 435-755-9174