Provider Demographics
NPI:1114164365
Name:SOUTHERN UTAH SURGICAL AND LASER AESTHETICS LLC
Entity Type:Organization
Organization Name:SOUTHERN UTAH SURGICAL AND LASER AESTHETICS LLC
Other - Org Name:RIVERSIDE MEDICAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-6466
Mailing Address - Street 1:1068 E RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4477
Mailing Address - Country:US
Mailing Address - Phone:435-628-6466
Mailing Address - Fax:
Practice Address - Street 1:1068 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4477
Practice Address - Country:US
Practice Address - Phone:435-628-6466
Practice Address - Fax:435-628-3845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty