Provider Demographics
NPI:1124208343
Name:GATEWAY AESTHEETIC INSTITUTE& LASER CENTER
Entity Type:Organization
Organization Name:GATEWAY AESTHEETIC INSTITUTE& LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-595-1600
Mailing Address - Street 1:440 W 200 S STE 250
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1462
Mailing Address - Country:US
Mailing Address - Phone:801-595-1600
Mailing Address - Fax:801-364-0423
Practice Address - Street 1:440 W 200 S STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1462
Practice Address - Country:US
Practice Address - Phone:801-595-1600
Practice Address - Fax:801-364-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT158056-8905284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital