Provider Demographics
NPI:1639815483
Name:UTAH WOUND CARE AND HYPERBARIC CENTER LLC
Entity Type:Organization
Organization Name:UTAH WOUND CARE AND HYPERBARIC CENTER LLC
Other - Org Name:UTAH WOUND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-587-9330
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-0848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:209 E GORDON AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2357
Practice Address - Country:US
Practice Address - Phone:385-786-6100
Practice Address - Fax:385-786-6101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12742218-0151OtherUT BUISNESS LICENSE REGISTRATION