Provider Demographics
NPI:1770188740
Name:NORTHERN UTAH SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORTHERN UTAH SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-787-7190
Mailing Address - Street 1:55 E GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-0001
Mailing Address - Country:US
Mailing Address - Phone:435-787-7190
Mailing Address - Fax:
Practice Address - Street 1:55 E GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-0001
Practice Address - Country:US
Practice Address - Phone:435-787-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical