Basic Information
| Provider Information | |||||||||
| NPI: | 1487296505 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | US SPORTS MEDICINE, LLC | ||||||||
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| OtherOrganizationName: | RAYUS RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741804 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900741804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666747933 | ||||||||
| FaxNumber: | 9525136880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1178 E BRICKYARD RD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841062555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015630333 | ||||||||
| FaxNumber: | 8015630335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | AHERN | ||||||||
| AuthorizedOfficialFirstName: | RAMONA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SPECIAL ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9527384441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| 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 | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.