Basic Information
| Provider Information | |||||||||
| NPI: | 1922396720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST SHORES SURGICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2792 S 5600 W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019699669 | ||||||||
| FaxNumber: | 8019699779 | ||||||||
| Practice Location | |||||||||
| Address1: | 2792 S 5600 W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019699669 | ||||||||
| FaxNumber: | 8019699779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 07/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | BIDDULPH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8019699669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NO HODADS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.