Provider Demographics
NPI:1255676920
Name:NORTHPOINTE SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:NORTHPOINTE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:COMBS
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MELODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-843-0180
Mailing Address - Street 1:2326 N 400 E STE 100
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3460
Mailing Address - Country:US
Mailing Address - Phone:435-843-0180
Mailing Address - Fax:435-843-0181
Practice Address - Street 1:2326 N 400 E STE 100
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3460
Practice Address - Country:US
Practice Address - Phone:435-843-0180
Practice Address - Fax:435-843-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6806D882440OtherGENERAL LIABILITY
UT46C0001058OtherMEDICARE CERTIFICATION NUMBER
UTU000086465OtherNORIDIAN PTAN NUMBER
UT2014-ASF-UT000647OtherPROFESSIONAL LICENSE
UT103541OtherAAAHC - ACCREDITATION
UT8929365-17014OtherPROFESSIONAL LICENSE PHARMACY CLASS B
UT6194OtherBUSINESS LICENSE - TOOELE
UT4310OtherX-RAY LICENSE NUMBER
UT46D2067524OtherCLIA
UT8929365-8913OtherPROFESSIONAL LICENSE CONTROLLED SUBSTANCE LICENSE
UTUT900010OtherMEDICAL MALPRACTICE
UTUT900010OtherMEDICAL MALPRACTICE