# FORM SURGERY CENTER LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457863912
- **Authorized official:** JANIE WARD (OWNER)
- **Authorized official phone:** (801) 513-3223

## Contact information

- **Practice address:** 6322 S 3000 E STE 170, SALT LAKE CITY, UT 84121-7290
- **Practice address phone:** (801) 513-3223
- **Mailing address:** 6322 S 3000 E STE 170, SALT LAKE CITY, UT 84121-7290
- **Mailing address phone:** (801) 513-3223

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 4972C | UT | Yes |

## Other

- **Enumeration date:** 10/24/2017
- **Last updated:** 04/05/2021