Provider Demographics
NPI:1184318826
Name:PLASTICS CLINIC LLC
Entity type:Organization
Organization Name:PLASTICS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-386-1337
Mailing Address - Street 1:1309 W SOUTH JORDAN PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9014
Mailing Address - Country:US
Mailing Address - Phone:801-839-5557
Mailing Address - Fax:801-770-4455
Practice Address - Street 1:1309 W SOUTH JORDAN PKWY STE 110
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9014
Practice Address - Country:US
Practice Address - Phone:801-839-5557
Practice Address - Fax:801-770-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty