Healthcare Provider Details

I. General information

NPI: 1487568382
Provider Name (Legal Business Name): ALTA SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 S 3000 E STE 170
SALT LAKE CITY UT
84121-7290
US

IV. Provider business mailing address

6322 S 3000 E STE 170
SALT LAKE CITY UT
84121-7290
US

V. Phone/Fax

Practice location:
  • Phone: 801-513-3223
  • Fax:
Mailing address:
  • Phone: 801-513-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JEREMY POULSEN
Title or Position: MANAGING MEMBER
Credential:
Phone: 559-313-6472