Healthcare Provider Details

I. General information

NPI: 1851545081
Provider Name (Legal Business Name): PREMIER PLASTIC SURGERY GROUP OF UTAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RENAISSANCE TOWNE DR SUITE 360
BOUNTIFUL UT
84010-7675
US

IV. Provider business mailing address

1551 RENAISSANCE TOWNE DR SUITE 360
BOUNTIFUL UT
84010-7675
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-9105
  • Fax: 801-295-9264
Mailing address:
  • Phone: 801-295-9105
  • Fax: 801-295-9264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number170345-1205
License Number StateUT

VIII. Authorized Official

Name: DR. JOSEPH GREGORY KJAR
Title or Position: PARTNER
Credential: M.D.
Phone: 801-295-9105