1659397313 NPI number — OREM SPORTS MEDICINE CENTER, LLC

Table of content: (NPI 1659397313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659397313 NPI number — OREM SPORTS MEDICINE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OREM SPORTS MEDICINE CENTER, LLC
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:
1659397313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
524 W 300 N STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84601-2669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-370-9981
Provider Business Mailing Address Fax Number:
801-370-9984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 E 800 N STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84097-4261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-226-0599
Provider Business Practice Location Address Fax Number:
801-226-3145
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUSHNELL
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-830-3034

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4739582-2401 , 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)





Copyright © 2007-2025 www.npivalidator.com