Provider Demographics
NPI:1790402170
Name:UTAH SPORTS AND ORTHOPEDICS
Entity Type:Organization
Organization Name:UTAH SPORTS AND ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-410-0205
Mailing Address - Street 1:2516 E SNOW MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2516 E SNOW MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-1858
Practice Address - Country:US
Practice Address - Phone:801-410-0205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty