Basic Information
| Provider Information | |||||||||
| NPI: | 1154573848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELEVATE SPORTS MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 W 400 N | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012219060 | ||||||||
| FaxNumber: | 8012219071 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 W 400 N | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840574658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012219060 | ||||||||
| FaxNumber: | 8012219071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8012219060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BS, ATC | ||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.