Provider Demographics
NPI:1659397313
Name:OREM SPORTS MEDICINE CENTER, LLC
Entity Type:Organization
Organization Name:OREM SPORTS MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:F
Authorized Official - Last Name:BUSHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-830-3034
Mailing Address - Street 1:524 W 300 N STE 201
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2669
Mailing Address - Country:US
Mailing Address - Phone:801-370-9981
Mailing Address - Fax:801-370-9984
Practice Address - Street 1:980 E 800 N STE 103
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4261
Practice Address - Country:US
Practice Address - Phone:801-226-0599
Practice Address - Fax:801-226-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4739582-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055866Medicare PIN