MEDICARE: UTAH SURGICAL 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		UT

General Provider Information

NPI Number	:	1629032305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH SURGICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 26211
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84126-0211
Country	:	US
Telephone Number	:	801-957-0200
Fax Number	:	801-957-0201

Provider Business Practice Location Address
First Line	:	3715 W 4100 S
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-5537
Country	:	US
Telephone Number	:	801-957-0200
Fax Number	:	801-957-0201

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. MARLA JENSEN
Credential	:	RN, BSN
Telephone Number	:	801-957-0200

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	04/20/2008

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