Healthcare Provider Details

I. General information

NPI: 1144509985
Provider Name (Legal Business Name): SOUTHWEST SPINE AND PAIN CARE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 05/01/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2891 E MALL DRIVE, STE. 101
SAINT GEORGE UT
84791
US

IV. Provider business mailing address

PO BOX 912042
SAINT GEORGE UT
84791-2042
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-2424
  • Fax: 435-656-2828
Mailing address:
  • Phone: 435-656-2424
  • Fax: 435-656-2828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY PFATENHAUER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 435-215-0230