Provider Demographics
NPI:1548366198
Name:VASCULAR CARE CENTER OF SALT LAKE LC
Entity type:Organization
Organization Name:VASCULAR CARE CENTER OF SALT LAKE LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-685-2900
Mailing Address - Street 1:1250 E 3900 S
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1348
Mailing Address - Country:US
Mailing Address - Phone:801-685-2900
Mailing Address - Fax:801-685-0440
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-685-2900
Practice Address - Fax:801-685-0440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055774Medicare PIN