Provider Demographics
NPI:1538698451
Name:UTAH PODIATRIC PHYSICIAN AND SURGEONS SPECIALIST GROUP, LLC
Entity Type:Organization
Organization Name:UTAH PODIATRIC PHYSICIAN AND SURGEONS SPECIALIST GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PREECE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-532-1822
Mailing Address - Street 1:144 S 700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1357
Mailing Address - Country:US
Mailing Address - Phone:801-532-1822
Mailing Address - Fax:801-527-5443
Practice Address - Street 1:5455 W 11000 N STE 203
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8802
Practice Address - Country:US
Practice Address - Phone:801-756-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7899779-0501213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty