Provider Demographics
NPI:1366989931
Name:ULTIMATE SPORTS REGENERATIVE MEDICINE
Entity type:Organization
Organization Name:ULTIMATE SPORTS REGENERATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-254-5800
Mailing Address - Street 1:1098 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9366
Mailing Address - Country:US
Mailing Address - Phone:801-254-5800
Mailing Address - Fax:801-254-1696
Practice Address - Street 1:1098 W. SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-254-5800
Practice Address - Fax:801-254-1696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ULTIMATE SPORTS REGENERATIVE MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7058178-1202111NI0013X
UT347183-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Multi-Specialty