Provider Demographics
NPI:1982915294
Name:COTTONWOOD SURGERY CENTER LLC
Entity Type:Organization
Organization Name:COTTONWOOD SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-261-1391
Mailing Address - Street 1:6053 S FASHION SQUARE DR
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5439
Mailing Address - Country:US
Mailing Address - Phone:801-262-0098
Mailing Address - Fax:
Practice Address - Street 1:6053 S FASHION SQUARE DR
Practice Address - Street 2:SUITE # 100
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5439
Practice Address - Country:US
Practice Address - Phone:801-262-0098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical