| Organization Name: | CANYON CREST SURGICAL, LLC |
| NPI Number: | 1205071198 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | VICKIE K GLAUSER (OFFICE STAFF) |
| Mailing Address: | 11762 S State #240 Draper |
| State: | UT US |
| Postal Code: | 84020 |
| Phone Number: | 8015427194 |
| Fax Number: | 8015427193 |
| NPI Enumeration Date: | 12/08/2008 |
| NPI Last Update Date: | 12/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA1903X |
| License Number: | 2008-ASF-86531 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Ambulatory Surgical |
| Taxonomy Definition: | |