Provider Demographics
NPI:1962463950
Name:CENTRAL UTAH SURGICAL CENTER L.L.C.
Entity Type:Organization
Organization Name:CENTRAL UTAH SURGICAL CENTER L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-0354
Mailing Address - Street 1:PO BOX 271472
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1472
Mailing Address - Country:US
Mailing Address - Phone:801-374-0354
Mailing Address - Fax:801-344-8929
Practice Address - Street 1:1067 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-0354
Practice Address - Fax:801-344-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2004-ASF-725261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87028102805001OtherBCBS
UT=========003Medicaid