Healthcare Provider Details

I. General information

NPI: 1386272755
Provider Name (Legal Business Name): ADVANCED VEIN AND VASCULAR OF SALT LAKE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 S REDWOOD RD STE 102
SALT LAKE CITY UT
84123-6799
US

IV. Provider business mailing address

6321 S REDWOOD RD STE 102
SALT LAKE CITY UT
84123-6799
US

V. Phone/Fax

Practice location:
  • Phone: 385-388-8003
  • Fax: 385-344-4006
Mailing address:
  • Phone: 385-388-8003
  • Fax: 385-344-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: LYNSEY NIELSEN
Title or Position: CLINICAL ADMINISTRATOR
Credential:
Phone: 385-388-8003