Provider Demographics
NPI:1417111394
Name:PROMISE HOSPITAL OF SALT LAKE INC
Entity Type:Organization
Organization Name:PROMISE HOSPITAL OF SALT LAKE INC
Other - Org Name:PROMISE HOSPITAL OF SALT LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:801-407-7110
Mailing Address - Street 1:8 TH AVE & C ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84143-0001
Mailing Address - Country:US
Mailing Address - Phone:801-408-7103
Mailing Address - Fax:
Practice Address - Street 1:8 TH AVE AND C ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-7103
Practice Address - Fax:801-408-7113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT9187437-17043336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100986OtherPK