Healthcare Provider Details

I. General information

NPI: 1326660374
Provider Name (Legal Business Name): JBR SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
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

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

V. Phone/Fax

Practice location:
  • Phone: 801-261-2000
  • Fax:
Mailing address:
  • Phone: 801-261-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANDRA WOODS
Title or Position: OR MANAGER
Credential:
Phone: 801-261-2000