MEDICARE: DR. LAUREN OPAL FLORENCE M.D.

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	2086S0122X	Plastic and Reconstructive Surgery Physician	180291	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180291	OTHER	UT	PHYSICIAN AND SURGEON

General Provider Information

NPI Number	:	1073729943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAUREN OPAL FLORENCE M.D.

Provider Business Mailing Address
First Line	:	1250 EAST 3900 SOUTH
Second Line	:	SUITE #301
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1362
Country	:	US
Telephone Number	:	801-264-9111
Fax Number	:	801-685-0440

Provider Business Practice Location Address
First Line	:	1250 EAST 3900 SOUTH
Second Line	:	SUITE #301
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1362
Country	:	US
Telephone Number	:	801-264-9111
Fax Number	:	801-685-0440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	12/16/2010

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