Healthcare Provider Details

I. General information

NPI: 1073677845
Provider Name (Legal Business Name): SPINE AND SPORTS MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 PIONEER PKWY SUITE 204
WEST VALLEY CITY UT
84120-2000
US

IV. Provider business mailing address

3065 OAK RIM LN
PARK CITY UT
84060-6804
US

V. Phone/Fax

Practice location:
  • Phone: 801-964-3249
  • Fax:
Mailing address:
  • Phone: 435-655-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number6053003-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number185699
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number6053003-1204
License Number StateUT

VIII. Authorized Official

Name: DR. CHARLES MIKELL BOVA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 435-640-6220