Provider Demographics
NPI:1215540968
Name:PARK TERRACE SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:PARK TERRACE SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-261-2000
Mailing Address - Street 1:650 E 4500 S STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4536
Mailing Address - Country:US
Mailing Address - Phone:801-261-2000
Mailing Address - Fax:801-261-4539
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:801-261-2000
Practice Address - Fax:801-261-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical