Healthcare Provider Details

I. General information

NPI: 1164965570
Provider Name (Legal Business Name): OLYMPUS VALLEY SURGICAL ASSOICATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 E 3900 S STE 4E
SALT LAKE CITY UT
84124-1343
US

IV. Provider business mailing address

PO BOX 99130
LAS VEGAS NV
89193-9130
US

V. Phone/Fax

Practice location:
  • Phone: 973-251-1132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN MARIE VAUGHN
Title or Position: OFFICER
Credential:
Phone: 973-251-1132