Provider Demographics
NPI:1851422703
Name:EXCEL COSMETIC SURGERY CENTER
Entity Type:Organization
Organization Name:EXCEL COSMETIC SURGERY CENTER
Other - Org Name:CENTRAL UTAH EYE ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-1818
Mailing Address - Street 1:1735 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1010
Mailing Address - Country:US
Mailing Address - Phone:801-379-2900
Mailing Address - Fax:801-374-6295
Practice Address - Street 1:1735 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1010
Practice Address - Country:US
Practice Address - Phone:801-379-2900
Practice Address - Fax:801-374-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT35910012052086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty