Healthcare Provider Details

I. General information

NPI: 1417833419
Provider Name (Legal Business Name): SALT LAKE ORTHOPAEDIC SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1184 E 80 N
AMERICAN FORK UT
84003-2906
US

IV. Provider business mailing address

PO BOX 30015 DEPT 379
SALT LAKE CITY UT
84130-0015
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-3885
  • Fax: 801-763-3887
Mailing address:
  • Phone: 801-505-0821
  • Fax: 801-505-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRENT A FELIX
Title or Position: MD/OWNER
Credential: MD
Phone: 801-284-8626