Healthcare Provider Details

I. General information

NPI: 1124298203
Provider Name (Legal Business Name): GATEWAY AESTHETIC INSTITUTE & LASER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W 200 S SUITE 250
SALT LAKE CITY UT
84101-1345
US

IV. Provider business mailing address

440 W 200 S SUITE 250
SALT LAKE CITY UT
84101-1345
US

V. Phone/Fax

Practice location:
  • Phone: 801-595-1600
  • Fax: 801-364-0423
Mailing address:
  • Phone: 801-595-1600
  • Fax: 801-364-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number5216196-8905
License Number StateUT

VIII. Authorized Official

Name: NANCY J SAMOLITIS
Title or Position: BOARD CERTIFIED DERMATOLOGIST
Credential: MD
Phone: 801-595-1600