Healthcare Provider Details

I. General information

NPI: 1902875669
Provider Name (Legal Business Name): NORTHERN UTAH ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E 1400 N SUITE 100A
LOGAN UT
84341-2534
US

IV. Provider business mailing address

630 E 1400 N SUITE 100A
LOGAN UT
84341-2534
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-0270
  • Fax: 435-787-0262
Mailing address:
  • Phone: 435-787-0270
  • Fax: 435-787-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2006-ASF-16794
License Number StateUT

VIII. Authorized Official

Name: DR. DUANE BOHMAN
Title or Position: MEMBER
Credential: MD
Phone: 435-787-0270