Provider Demographics
NPI:1689813446
Name:ELITE PERFORMANCE HEALTH CENTER, PC
Entity Type:Organization
Organization Name:ELITE PERFORMANCE HEALTH CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-302-0280
Mailing Address - Street 1:3630 W SOUTH JORDAN PARKWAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7153
Mailing Address - Country:US
Mailing Address - Phone:801-302-0280
Mailing Address - Fax:801-303-5040
Practice Address - Street 1:3630 W SOUTH JORDAN PARKWAY
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-7153
Practice Address - Country:US
Practice Address - Phone:801-302-0280
Practice Address - Fax:801-303-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5188785-1202111NS0005X
UT111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU92486Medicare UPIN