Healthcare Provider Details

I. General information

NPI: 1932279403
Provider Name (Legal Business Name): VIVACE VEIN CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 E 800 N SUITE 205
OREM UT
84097-4435
US

IV. Provider business mailing address

1375 E 800 N SUITE 205
OREM UT
84097-4435
US

V. Phone/Fax

Practice location:
  • Phone: 801-785-1701
  • Fax: 801-404-5781
Mailing address:
  • Phone: 801-785-1701
  • Fax: 801-404-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARK WOOD
Title or Position: PRESIDENT
Credential:
Phone: 801-785-1701