MEDICARE: VINCENT SURGICAL ARTS, 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	2086S0122X	Plastic and Reconstructive Surgery Physician	5767298-8905	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5828175-0160	OTHER	UT	BUSINESS ENTITY

General Provider Information

NPI Number	:	1538572169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINCENT SURGICAL ARTS, LLC

Provider Business Mailing Address
First Line	:	6710 S BLACKSTONE RD
Second Line	:	SUITE 201
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6072
Country	:	US
Telephone Number	:	801-942-1111
Fax Number	:	801-942-1188

Provider Business Practice Location Address
First Line	:	6710 S BLACKSTONE RD
Second Line	:	SUITE 201
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6072
Country	:	US
Telephone Number	:	801-942-1111
Fax Number	:	801-942-1188

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. DRAKE G VINCENT
Credential	:	M.D.
Telephone Number	:	801-942-1111

Provider Enumeration Date	:	06/11/2014
Last Update Date	:	06/11/2014

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