Healthcare Provider Details

I. General information

NPI: 1710644463
Provider Name (Legal Business Name): ELITE ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 E 800 N STE 104
OREM UT
84097-4261
US

IV. Provider business mailing address

PO BOX 1169
BOUNTIFUL UT
84011-1169
US

V. Phone/Fax

Practice location:
  • Phone: 801-252-4888
  • Fax: 801-252-4887
Mailing address:
  • Phone: 801-252-4888
  • Fax: 801-252-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW POULSEN
Title or Position: OWNER
Credential:
Phone: 801-252-4888