Provider Demographics
NPI:1750704920
Name:SOUTH OGDEN SPECIALTY SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:SOUTH OGDEN SPECIALTY SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:COWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-317-4896
Mailing Address - Street 1:955 CHAMBERS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4595
Mailing Address - Country:US
Mailing Address - Phone:801-317-4896
Mailing Address - Fax:801-605-8226
Practice Address - Street 1:955 CHAMBERS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4595
Practice Address - Country:US
Practice Address - Phone:801-317-4896
Practice Address - Fax:801-605-8226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical