Healthcare Provider Details

I. General information

NPI: 1104301613
Provider Name (Legal Business Name): LOGAN SURGICAL SUITES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 EAST GOLF COURSE ROAD
LOGAN UT
84321-0001
US

IV. Provider business mailing address

55 EAST GOLF COURSE ROAD
LOGAN UT
84321-0001
US

V. Phone/Fax

Practice location:
  • Phone: 435-760-3734
  • Fax:
Mailing address:
  • Phone: 435-787-7190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIELLE WHITLOCK
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 435-760-3734