Provider Demographics
NPI:1215057955
Name:INTERMOUNTAIN SPINE AND PAIN CENTER
Entity type:Organization
Organization Name:INTERMOUNTAIN SPINE AND PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:KARTSONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-753-1600
Mailing Address - Street 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:286 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9733
Practice Address - Country:US
Practice Address - Phone:435-753-1600
Practice Address - Fax:435-753-9521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0329116-1204261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid