Provider Demographics
NPI:1124079843
Name:MOUNTAINWEST SURGICAL CENTER LLC
Entity type:Organization
Organization Name:MOUNTAINWEST SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-383-1111
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7668
Mailing Address - Country:US
Mailing Address - Phone:801-383-1111
Mailing Address - Fax:801-383-1115
Practice Address - Street 1:1551 S RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-383-1111
Practice Address - Fax:801-383-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-31532261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870630186001Medicaid
UT870630186001Medicaid