Healthcare Provider Details

I. General information

NPI: 1285313452
Provider Name (Legal Business Name): ELEVATED PERFORMANCE AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 E 5600 S
OGDEN UT
84403
US

IV. Provider business mailing address

1214 E 3150 N
OGDEN UT
84414-1838
US

V. Phone/Fax

Practice location:
  • Phone: 801-689-2546
  • Fax:
Mailing address:
  • Phone: 203-895-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY EUGENE SPEICHER
Title or Position: PRESIDENT
Credential: PHD, AT, LAT, CSCS
Phone: 801-689-2546