Provider Demographics
NPI:1992342414
Name:INTERVENTIONAL SPINE & PAIN MANAGEMENT
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE & PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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 1:1276 WALL AVE STE 2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5673
Practice Address - Country:US
Practice Address - Phone:801-262-7246
Practice Address - Fax:801-262-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty