Provider Demographics
NPI:1710644463
Name:ELITE ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ELITE ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-252-4888
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1169
Mailing Address - Country:US
Mailing Address - Phone:801-252-4888
Mailing Address - Fax:801-252-4887
Practice Address - Street 1:980 E 800 N STE 104
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:801-252-4888
Practice Address - Fax:801-252-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty