Healthcare Provider Details

I. General information

NPI: 1104361591
Provider Name (Legal Business Name): GENESIS VASCULAR OF SALT LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 S REDWOOD RD SUITE 102
SALT LAKE CITY UT
84123-6798
US

IV. Provider business mailing address

6321 S REDWOOD RD STE 102
TAYLORSVILLE UT
84123-6799
US

V. Phone/Fax

Practice location:
  • Phone: 385-388-8003
  • Fax: 385-344-4006
Mailing address:
  • Phone: 385-388-8003
  • Fax: 385-344-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DENNIS MUNFORD
Title or Position: MANAGER
Credential:
Phone: 385-388-8003