Provider Demographics
NPI:1538572169
Name:VINCENT SURGICAL ARTS, LLC
Entity type:Organization
Organization Name:VINCENT SURGICAL ARTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DRAKE
Authorized Official - Middle Name:G
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-942-1111
Mailing Address - Street 1:6710 S BLACKSTONE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6072
Mailing Address - Country:US
Mailing Address - Phone:801-942-1111
Mailing Address - Fax:801-942-1188
Practice Address - Street 1:6710 S BLACKSTONE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-6072
Practice Address - Country:US
Practice Address - Phone:801-942-1111
Practice Address - Fax:801-942-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5767298-89052086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5828175-0160OtherBUSINESS ENTITY