Provider Demographics
NPI:1811913429
Name:SALT LAKE ORTHOPAEDIC SPECIALIST, LLC
Entity type:Organization
Organization Name:SALT LAKE ORTHOPAEDIC SPECIALIST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FELIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-262-8486
Mailing Address - Street 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:1521 E 3900 S STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1501
Practice Address - Country:US
Practice Address - Phone:801-262-8486
Practice Address - Fax:801-284-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========009Medicaid
UT4415240001Medicare NSC
UT000055905Medicare PIN