Healthcare Provider Details

I. General information

NPI: 1053201525
Provider Name (Legal Business Name): WASATCH SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MEDICAL DR STE 300
BOUNTIFUL UT
84010-8925
US

IV. Provider business mailing address

1893 E MILLBROOK RD
SALT LAKE CITY UT
84106-3827
US

V. Phone/Fax

Practice location:
  • Phone: 228-273-9021
  • Fax:
Mailing address:
  • Phone: 228-273-9021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MACKENZIE LEE GOODWIN
Title or Position: OWNER
Credential: MD
Phone: 228-273-9021