Healthcare Provider Details

I. General information

NPI: 1750263745
Provider Name (Legal Business Name): NORTHERN UTAH SURGICENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E GOLF COURSE RD
LOGAN UT
84321-0001
US

IV. Provider business mailing address

55 E GOLF COURSE RD
LOGAN UT
84321-0001
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-7190
  • Fax: 435-787-7197
Mailing address:
  • Phone: 435-787-7190
  • Fax: 435-787-7197

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: DAVID MCKNIGHT
Title or Position: CFO
Credential:
Phone: 972-789-2816