Provider Demographics
NPI:1699209221
Name:MOUNTAIN SPINE PC
Entity type:Organization
Organization Name:MOUNTAIN SPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SNOOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:385-414-7080
Mailing Address - Street 1:63 E 11400 S # 245
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6705
Mailing Address - Country:US
Mailing Address - Phone:385-414-7080
Mailing Address - Fax:385-325-0004
Practice Address - Street 1:11613 S STATE ST
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9456
Practice Address - Country:US
Practice Address - Phone:385-414-7080
Practice Address - Fax:385-325-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5688087-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty