MEDICARE: OLYMPUS SURGERY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1346198173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPUS SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3130 S HIGHLAND DR STE B4
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-3095
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 E 4500 S STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2901
Country	:	US
Telephone Number	:	801-253-6886
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RYAN S ELLSWORTH
Credential	:	DPM
Telephone Number	:	801-253-6886

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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