Provider Demographics
NPI:1710192034
Name:MOUNTAIN VIEW ORTHOPEDICS AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:MOUNTAIN VIEW ORTHOPEDICS AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-475-5683
Mailing Address - Street 1:1486 E SKYLINE DR
Mailing Address - Street 2:STE 202
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4863
Mailing Address - Country:US
Mailing Address - Phone:801-475-5683
Mailing Address - Fax:801-475-9499
Practice Address - Street 1:1486 E SKYLINE DR
Practice Address - Street 2:STE 202
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4863
Practice Address - Country:US
Practice Address - Phone:801-475-5683
Practice Address - Fax:801-475-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5181983-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5412590001Medicare NSC
UT000057505Medicare PIN