Provider Demographics
NPI:1407410244
Name:PROVAS OF SALT LAKE, LLC
Entity Type:Organization
Organization Name:PROVAS OF SALT LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-386-4240
Mailing Address - Street 1:909 E 9400 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5514
Mailing Address - Country:US
Mailing Address - Phone:801-386-4240
Mailing Address - Fax:
Practice Address - Street 1:909 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5514
Practice Address - Country:US
Practice Address - Phone:801-386-4240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty