MEDICARE: ADVANCED VEIN AND VASCULAR OF UTAH VALLEY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician

General Provider Information

NPI Number	:	1093329427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED VEIN AND VASCULAR OF UTAH VALLEY LLC

Provider Business Mailing Address
First Line	:	6321 S REDWOOD RD STE 102
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-6799
Country	:	US
Telephone Number	:	385-388-8003
Fax Number	:	385-344-4006

Provider Business Practice Location Address
First Line	:	591 N STATE ROAD 198 # 202
Second Line	:
City	:	SALEM
State	:	UT
Zip	:	84653-5668
Country	:	US
Telephone Number	:	385-388-8003
Fax Number	:	385-344-4006

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LYNSEY NIELSEN
Credential	:
Telephone Number	:	385-388-8003

Provider Enumeration Date	:	09/02/2020
Last Update Date	:	08/08/2022

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