Healthcare Provider Details

I. General information

NPI: 1184245169
Provider Name (Legal Business Name): WASATCH VASCULAR CENTER ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 S STATE ST
SALT LAKE CITY UT
84115-5078
US

IV. Provider business mailing address

40 VALLEY STREAM PKWY STE 100
MALVERN PA
19355-1407
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-0027
  • Fax:
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

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: GREGG MILLER
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 717-515-4048