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General NPI Number Information
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NPI Number | 1053201525
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Entity Type | Organization
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Legal Business Name | WASATCH SURGICAL LLC
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Dates
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Enumeration Date | 07/07/2025
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Last Update Date | 07/07/2025
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Provider Practice Location Address
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Address Line | 520 MEDICAL DR STE 300
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City | BOUNTIFUL
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State | UT
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Zip | 84010-8925
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Country | US
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Telephone | 228-273-9021
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Fax |
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Provider Business Mailing Address
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Address Line | 1893 E MILLBROOK RD
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-3827
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Country | US
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Telephone | 228-273-9021
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MACKENZIE LEE GOODWIN
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Credential | MD
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Telephone | 228-273-9021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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