Provider Demographics
NPI:1114959616
Name:ADVANCED ORTHOPEDICS AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ADVANCED ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-568-3480
Mailing Address - Street 1:8785 JORDAN VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9772
Mailing Address - Country:US
Mailing Address - Phone:801-568-3480
Mailing Address - Fax:801-568-3482
Practice Address - Street 1:8785 JORDAN VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9772
Practice Address - Country:US
Practice Address - Phone:801-568-3480
Practice Address - Fax:801-568-3482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT22772174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH78126Medicare UPIN