Healthcare Provider Details

I. General information

NPI: 1043884604
Provider Name (Legal Business Name): WILLOW BEND SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E 4500 S STE 100
SALT LAKE CITY UT
84107-4536
US

IV. Provider business mailing address

1809 E INDIAN WELLS LN
DRAPER UT
84020-8301
US

V. Phone/Fax

Practice location:
  • Phone: 801-450-6940
  • Fax: 801-944-5910
Mailing address:
  • Phone: 801-450-6940
  • Fax: 801-944-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW PAUL WOOD
Title or Position: PRESIDENT
Credential: DC
Phone: 801-450-6940