Provider Demographics
NPI:1629032305
Name:UTAH SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:UTAH SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:801-957-0200
Mailing Address - Street 1:PO BOX 26211
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0211
Mailing Address - Country:US
Mailing Address - Phone:801-957-0200
Mailing Address - Fax:801-957-0201
Practice Address - Street 1:3715 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5537
Practice Address - Country:US
Practice Address - Phone:801-957-0200
Practice Address - Fax:801-957-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid