Provider Demographics
NPI:1043884604
Name:WILLOW BEND SURGICAL CENTER
Entity Type:Organization
Organization Name:WILLOW BEND SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-450-6940
Mailing Address - Street 1:1809 E INDIAN WELLS LN
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8301
Mailing Address - Country:US
Mailing Address - Phone:801-450-6940
Mailing Address - Fax:801-944-5910
Practice Address - Street 1:650 E 4500 S STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-4536
Practice Address - Country:US
Practice Address - Phone:801-450-6940
Practice Address - Fax:801-944-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical