Basic Information
| Provider Information | |||||||||
| NPI: | 1043884604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLOW BEND SURGICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1809 E INDIAN WELLS LN | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840208301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014506940 | ||||||||
| FaxNumber: | 8019445910 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 E 4500 S STE 100 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841074536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014506940 | ||||||||
| FaxNumber: | 8019445910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2021 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8014506940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.