Provider Demographics
NPI:1104361591
Name:GENESIS VASCULAR OF SALT LAKE
Entity Type:Organization
Organization Name:GENESIS VASCULAR OF SALT LAKE
Other - Org Name:GENESIS VASCULAR OF SALT LAKE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-388-8003
Mailing Address - Street 1:6321 S REDWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6799
Mailing Address - Country:US
Mailing Address - Phone:385-388-8003
Mailing Address - Fax:385-344-4006
Practice Address - Street 1:6321 S REDWOOD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-6798
Practice Address - Country:US
Practice Address - Phone:385-388-8003
Practice Address - Fax:385-344-4006
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS VASCULAR OF SALT LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty