Healthcare Provider Details

I. General information

NPI: 1780885442
Provider Name (Legal Business Name): LYSSA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E 500 S
SALT LAKE CITY UT
84102-2746
US

IV. Provider business mailing address

2056 HUBBARD AVE
SALT LAKE CITY UT
84108-1306
US

V. Phone/Fax

Practice location:
  • Phone: 801-824-6007
  • Fax:
Mailing address:
  • Phone: 801-824-6007
  • Fax:

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: MS. CHRISTIE MCCUTCHAN
Title or Position: OWNER
Credential:
Phone: 801-262-0807