Provider Demographics
NPI:1588407142
Name:WISE CLEFT CENTER FOR EXCELLENCE LLC
Entity type:Organization
Organization Name:WISE CLEFT CENTER FOR EXCELLENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-669-7660
Mailing Address - Street 1:11762 S STATE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7158
Mailing Address - Country:US
Mailing Address - Phone:385-218-0587
Mailing Address - Fax:385-381-4447
Practice Address - Street 1:11762 S STATE ST STE 110
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7158
Practice Address - Country:US
Practice Address - Phone:385-977-8125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty