1538572169 NPI number — VINCENT SURGICAL ARTS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538572169 NPI number — VINCENT SURGICAL ARTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCENT SURGICAL ARTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538572169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6710 S BLACKSTONE RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
COTTONWOOD HEIGHTS
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84121-6072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-942-1111
Provider Business Mailing Address Fax Number:
801-942-1188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6710 S BLACKSTONE RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COTTONWOOD HEIGHTS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84121-6072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-942-1111
Provider Business Practice Location Address Fax Number:
801-942-1188
Provider Enumeration Date:
06/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VINCENT
Authorized Official First Name:
DRAKE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
801-942-1111

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  5767298-8905 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5828175-0160 . This is a "BUSINESS ENTITY" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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