Healthcare Provider Details

I. General information

NPI: 1336264050
Provider Name (Legal Business Name): UTAH VASCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 205
PROVO UT
84604-5044
US

IV. Provider business mailing address

1055 N 300 W STE 205
PROVO UT
84604-5044
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9100
  • Fax: 801-374-9117
Mailing address:
  • Phone: 801-374-9100
  • Fax: 801-374-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: LEON JAMES JENSEN JR.
Title or Position: COO
Credential:
Phone: 801-225-6246