Healthcare Provider Details

I. General information

NPI: 1497924229
Provider Name (Legal Business Name): ENT SURGICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 N 400 E 202
TOOELE UT
84074-9838
US

IV. Provider business mailing address

2376 N 400 E STE 202
TOOELE UT
84074-9838
US

V. Phone/Fax

Practice location:
  • Phone: 435-833-9600
  • Fax: 435-882-4743
Mailing address:
  • Phone: 435-833-9600
  • Fax: 435-882-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateUT

VIII. Authorized Official

Name: LORE COOPER
Title or Position: OFFICE MANAGER
Credential:
Phone: 435-833-9600