1689813446 NPI number — ELITE PERFORMANCE HEALTH CENTER, PC

Table of content: (NPI 1689813446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689813446 NPI number — ELITE PERFORMANCE HEALTH CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE PERFORMANCE HEALTH CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689813446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3630 W SOUTH JORDAN PARKWAY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-7153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-302-0280
Provider Business Mailing Address Fax Number:
801-303-5040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 W SOUTH JORDAN PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SOUTH JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84095-7153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-302-0280
Provider Business Practice Location Address Fax Number:
801-303-5040
Provider Enumeration Date:
02/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
801-302-0280

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  5188785-1202 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NS0005X , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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