Provider Demographics
NPI:1790906204
Name:EAR, NOSE & THROAT SURGERY CENTER OF UTAH LLC
Entity type:Organization
Organization Name:EAR, NOSE & THROAT SURGERY CENTER OF UTAH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-694-2802
Mailing Address - Street 1:9450 S 1300 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5555
Mailing Address - Country:US
Mailing Address - Phone:801-924-2878
Mailing Address - Fax:801-924-2888
Practice Address - Street 1:9450 S 1300 E STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5555
Practice Address - Country:US
Practice Address - Phone:801-924-2878
Practice Address - Fax:801-924-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20042178261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid