Provider Demographics
NPI:1508040221
Name:FAMILY SURGICAL SUITE
Entity type:Organization
Organization Name:FAMILY SURGICAL SUITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:DEHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-495-1064
Mailing Address - Street 1:8822 S REDWOOD RD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9336
Mailing Address - Country:US
Mailing Address - Phone:801-495-1064
Mailing Address - Fax:801-523-1139
Practice Address - Street 1:8822 S REDWOOD RD
Practice Address - Street 2:SUITE 113
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9336
Practice Address - Country:US
Practice Address - Phone:801-495-1064
Practice Address - Fax:801-523-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical