Healthcare Provider Details

I. General information

NPI: 1265638357
Provider Name (Legal Business Name): MOUNTAINSTAR SPECIALTY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 S STE 460
SALT LAKE CITY UT
84124-1348
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4525
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-3564
  • Fax: 801-262-3613
Mailing address:
  • Phone: 615-373-7406
  • Fax: 866-346-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateUT

VIII. Authorized Official

Name: LOUIS JOSEPH
Title or Position: VP
Credential:
Phone: 615-373-7630