=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184318826
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLASTICS CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 10/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1309 W SOUTH JORDAN PKWY STE 110
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-839-5557
-----------------------------------------------------
Fax | 801-770-4455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 W SOUTH JORDAN PKWY STE 110
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-9014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-839-5557
-----------------------------------------------------
Fax | 801-770-4455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TIM PRUSSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-386-1337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------