Basic Information
| Provider Information | |||||||||
| NPI: | 1477081412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTA CANYON SPINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5770 S 250 E STE 135 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841078241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013142225 | ||||||||
| FaxNumber: | 8013142345 | ||||||||
| Practice Location | |||||||||
| Address1: | 5770 S 250 E STE 135 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841078241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013142225 | ||||||||
| FaxNumber: | 8013142345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOHL | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | BURNELL | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 8013142225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 1639371149 | 01 | UT | NPI | OTHER |