Healthcare Provider Details

I. General information

NPI: 1366989931
Provider Name (Legal Business Name): ULTIMATE SPORTS REGENERATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1098 W. SOUTH JORDAN PKWY SUITE 101
SOUTH JORDAN UT
84095
US

IV. Provider business mailing address

1098 W SOUTH JORDAN PKWY SUITE 101
SOUTH JORDAN UT
84095-9366
US

V. Phone/Fax

Practice location:
  • Phone: 801-254-5800
  • Fax: 801-254-1696
Mailing address:
  • Phone: 801-254-5800
  • Fax: 801-254-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number7058178-1202
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number347183-4405
License Number StateUT

VIII. Authorized Official

Name: PATRICK GARCIA
Title or Position: DIRECT OWNER
Credential:
Phone: 801-254-5800