Healthcare Provider Details

I. General information

NPI: 1558439117
Provider Name (Legal Business Name): WESTSIDE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 NORTH 2000 WEST
CLINTON UT
84015-8213
US

IV. Provider business mailing address

1477 NORTH 2000 WEST
CLINTON UT
84015-8213
US

V. Phone/Fax

Practice location:
  • Phone: 801-774-8888
  • Fax: 801-825-8519
Mailing address:
  • Phone: 801-774-8888
  • Fax: 801-825-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN SEPER
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-774-8888