Provider Demographics
NPI:1831202118
Name:LAKEVIEW NEUROSURGERY CLINIC, LLC
Entity type:Organization
Organization Name:LAKEVIEW NEUROSURGERY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-299-3871
Mailing Address - Street 1:620 MEDICAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5084
Mailing Address - Country:US
Mailing Address - Phone:801-299-3871
Mailing Address - Fax:
Practice Address - Street 1:620 MEDICAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5084
Practice Address - Country:US
Practice Address - Phone:801-299-3871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty