Provider Demographics
NPI:1124298203
Name:GATEWAY AESTHETIC INSTITUTE & LASER CENTER
Entity type:Organization
Organization Name:GATEWAY AESTHETIC INSTITUTE & LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED DERMATOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMOLITIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-595-1600
Mailing Address - Street 1:440 W 200 S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1345
Mailing Address - Country:US
Mailing Address - Phone:801-595-1600
Mailing Address - Fax:801-364-0423
Practice Address - Street 1:440 W 200 S
Practice Address - Street 2:SUITE 250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1345
Practice Address - Country:US
Practice Address - Phone:801-595-1600
Practice Address - Fax:801-364-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5216196-8905282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural