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General NPI Number Information
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NPI Number | 1679453781
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Entity Type | Organization
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Legal Business Name | THE SPORTS MED SPA LLC
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Dates
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Enumeration Date | 09/08/2025
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Last Update Date | 10/16/2025
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Provider Practice Location Address
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Address Line | 3580 W 9000 S
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City | WEST JORDAN
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State | UT
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Zip | 84088-8812
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Country | US
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Telephone | 801-448-2218
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Fax |
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Provider Business Mailing Address
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Address Line | 4645 W S JORDAN PKWY
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City | SOUTH JORDAN
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State | UT
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Zip | 84009-5761
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GIBRAN BORJA
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Credential |
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Telephone | 801-448-2218
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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