Provider Demographics
NPI:1831424324
Name:MOUNTAINSTAR CANYON SURGICAL CLINIC LLC
Entity type:Organization
Organization Name:MOUNTAINSTAR CANYON SURGICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-569-5933
Mailing Address - Street 1:984 MEDICAL DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3604
Mailing Address - Country:US
Mailing Address - Phone:435-723-0329
Mailing Address - Fax:435-723-0429
Practice Address - Street 1:984 MEDICAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3604
Practice Address - Country:US
Practice Address - Phone:435-723-0329
Practice Address - Fax:435-723-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1831424324Medicaid
UT000068109Medicare PIN
DP6414Medicare PIN