Basic Information
Provider Information | |||||||||
NPI: | 1376144758 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | US SPORTS MEDICINE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RAYUS RADIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 741804 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900741804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8666747933 | ||||||||
FaxNumber: | 9525136880 | ||||||||
Practice Location | |||||||||
Address1: | 729 KING ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | LAYTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840414681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015630333 | ||||||||
FaxNumber: | 8015630335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2020 | ||||||||
LastUpdateDate: | 08/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AHERN | ||||||||
AuthorizedOfficialFirstName: | RAMONA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIAL ASSISTANT SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 9527384441 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.