MEDICARE: ALTA BELLA PLASTIC SURGERY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1023721537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTA BELLA PLASTIC SURGERY PLLC

Provider Business Mailing Address
First Line	:	370 E 9TH AVE STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-3185
Country	:	US
Telephone Number	:	801-613-1626
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 E 9TH AVE STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-3185
Country	:	US
Telephone Number	:	801-613-1626
Fax Number	:

Authorized Official
Title or Position	:	SURGEON/OWNER
Name	:	DR. MELODY SCHEEFER VAN BOERUM
Credential	:	MD
Telephone Number	:	801-613-1626

Provider Enumeration Date	:	12/29/2022
Last Update Date	:	12/29/2022

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