Provider Demographics
NPI:1992550974
Name:THE BLADDER CLINIC LLC
Entity type:Organization
Organization Name:THE BLADDER CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIMADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-628-8260
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-0432
Mailing Address - Country:US
Mailing Address - Phone:801-589-4033
Mailing Address - Fax:
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR STE 460
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7672
Practice Address - Country:US
Practice Address - Phone:844-764-7633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty