Provider Demographics
NPI:1053201525
Name:WASATCH SURGICAL LLC
Entity type:Organization
Organization Name:WASATCH SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-273-9021
Mailing Address - Street 1:1893 E MILLBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3827
Mailing Address - Country:US
Mailing Address - Phone:228-273-9021
Mailing Address - Fax:
Practice Address - Street 1:520 MEDICAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8925
Practice Address - Country:US
Practice Address - Phone:228-273-9021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty