Provider Demographics
NPI:1669415451
Name:BOUNTIFUL SURGERY CENTER LLC
Entity type:Organization
Organization Name:BOUNTIFUL SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:SWINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-789-2877
Mailing Address - Street 1:620 MEDICAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4908
Mailing Address - Country:US
Mailing Address - Phone:801-296-2698
Mailing Address - Fax:801-296-2122
Practice Address - Street 1:620 MEDICAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-296-2698
Practice Address - Fax:801-296-2122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000059228Medicare PIN