Provider Demographics
NPI:1073677845
Name:SPINE AND SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:SPINE AND SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MIKELL
Authorized Official - Last Name:BOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-640-6220
Mailing Address - Street 1:3065 OAK RIM LN
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-6804
Mailing Address - Country:US
Mailing Address - Phone:435-655-8468
Mailing Address - Fax:
Practice Address - Street 1:3336 PIONEER PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2000
Practice Address - Country:US
Practice Address - Phone:801-964-3249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6053003-1204204C00000X, 208VP0014X
UT1856992081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Not Answered2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Not Answered208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty