Provider Demographics
NPI:1215027099
Name:BRIGHAM YOUNG UNIVERSITY
Entity Type:Organization
Organization Name:BRIGHAM YOUNG UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ATHLETIC DIRECTOR/CONTROL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-422-2098
Mailing Address - Street 1:1130 SFH SPORTS MED
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:801-377-6918
Mailing Address - Fax:801-377-6919
Practice Address - Street 1:1130 SFH SPORTS MED
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-377-6918
Practice Address - Fax:801-377-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherTAX ID NUMBER