Provider Demographics
NPI:1386272755
Name:ADVANCED VEIN AND VASCULAR OF SALT LAKE CITY LLC
Entity type:Organization
Organization Name:ADVANCED VEIN AND VASCULAR OF SALT LAKE CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-388-8003
Mailing Address - Street 1:6321 S REDWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6799
Mailing Address - Country:US
Mailing Address - Phone:385-388-8003
Mailing Address - Fax:385-344-4006
Practice Address - Street 1:6321 S REDWOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-6799
Practice Address - Country:US
Practice Address - Phone:385-388-8003
Practice Address - Fax:385-344-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-31
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty