Healthcare Provider Details

I. General information

NPI: 1790906204
Provider Name (Legal Business Name): EAR, NOSE & THROAT SURGERY CENTER OF UTAH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 S 1300 E STE 100
SANDY UT
84094-5555
US

IV. Provider business mailing address

9450 S 1300 E STE 100
SANDY UT
84094-5555
US

V. Phone/Fax

Practice location:
  • Phone: 801-924-2878
  • Fax: 801-924-2888
Mailing address:
  • Phone: 801-924-2878
  • Fax: 801-924-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number20042178
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STEPHEN LARSON
Title or Position: OWNER
Credential: MD
Phone: 801-694-2802