Healthcare Provider Details

I. General information

NPI: 1790796480
Provider Name (Legal Business Name): ULTIMATE SPORTS & ORTHOPAEDICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15990 TUSCOLA RD
APPLE VALLEY CA
92307-2111
US

IV. Provider business mailing address

15990 TUSCOLA RD
APPLE VALLEY CA
92307-2111
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-4808
  • Fax: 760-242-4889
Mailing address:
  • Phone: 760-242-4808
  • Fax: 760-242-4889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL HENRY RICE
Title or Position: PRESIDENT
Credential: MD
Phone: 760-242-4808