Provider Demographics
NPI:1780885442
Name:LYSSA INC
Entity type:Organization
Organization Name:LYSSA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUTCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-262-0807
Mailing Address - Street 1:2056 HUBBARD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1306
Mailing Address - Country:US
Mailing Address - Phone:801-824-6007
Mailing Address - Fax:
Practice Address - Street 1:530 E 500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2746
Practice Address - Country:US
Practice Address - Phone:801-824-6007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical