Healthcare Provider Details

I. General information

NPI: 1881870434
Provider Name (Legal Business Name): SELAROM SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5089 S 900 E #100
SALT LAKE CITY UT
84117-5735
US

IV. Provider business mailing address

5089 S 900 E #100
SALT LAKE CITY UT
84117-5735
US

V. Phone/Fax

Practice location:
  • Phone: 801-743-0700
  • Fax: 801-743-0701
Mailing address:
  • Phone: 801-743-0700
  • Fax: 801-743-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LOUIS MORALES JR.
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 801-743-0700