Healthcare Provider Details

I. General information

NPI: 1376144758
Provider Name (Legal Business Name): US SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 KING ST STE 100
LAYTON UT
84041-4681
US

IV. Provider business mailing address

PO BOX 741804
LOS ANGELES CA
90074-1804
US

V. Phone/Fax

Practice location:
  • Phone: 801-563-0333
  • Fax: 801-563-0335
Mailing address:
  • Phone: 866-674-7933
  • Fax: 952-513-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. RAMONA L AHERN
Title or Position: SPECIAL ASSISTANT SECRETARY
Credential:
Phone: 952-738-4441