=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699209221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN SPINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2017
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11613 S STATE ST
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-9456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-414-7080
-----------------------------------------------------
Fax | 385-325-0004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 E 11400 S # 245
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84070-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-414-7080
-----------------------------------------------------
Fax | 385-325-0004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR/ OWNER
-----------------------------------------------------
Name | GARY D SNOOK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 385-414-7080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5688087-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------