Healthcare Provider Details

I. General information

NPI: 1609896216
Provider Name (Legal Business Name): SALT LAKE ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 103
SALT LAKE CITY UT
84102-1592
US

IV. Provider business mailing address

24 SOUTH 1100 EAST #103
SALT LAKE CITY UT
84102
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-2987
  • Fax: 801-531-9704
Mailing address:
  • Phone: 801-355-2987
  • Fax: 801-531-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2006-ASF-332
License Number StateUT

VIII. Authorized Official

Name: DR. STEWART L ELLINGTON
Title or Position: PRESIDENT
Credential: DR
Phone: 801-364-5767