Provider Demographics
NPI:1205071198
Name:CANYON CREST SURGICAL, LLC
Entity type:Organization
Organization Name:CANYON CREST SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE STAFF
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:GLAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-316-1313
Mailing Address - Street 1:11762 S STATE #240
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020
Mailing Address - Country:US
Mailing Address - Phone:801-542-7194
Mailing Address - Fax:801-542-7193
Practice Address - Street 1:11762 S STATE #240
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020
Practice Address - Country:US
Practice Address - Phone:801-542-7194
Practice Address - Fax:801-542-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2008-ASF-86531261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical