Provider Demographics
NPI:1790280816
Name:STONE MOUNTAIN SURGICAL, LLC
Entity Type:Organization
Organization Name:STONE MOUNTAIN SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIFERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-571-2295
Mailing Address - Street 1:6905 S 1300 E STE 161
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1817
Mailing Address - Country:US
Mailing Address - Phone:801-571-2295
Mailing Address - Fax:801-206-3770
Practice Address - Street 1:6804 S 1300 E
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-2882
Practice Address - Country:US
Practice Address - Phone:801-571-2295
Practice Address - Fax:801-206-3770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment