| Organization Name: | SPINE AND SPORTS MEDICINE INC |
| NPI Number: | 1073677845 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CHARLES MIKELL BOVA (PRESIDENT) |
| Mailing Address: | 3336 Pioneer Pkwy Suite 204 West Valley City |
| State: | UT US |
| Postal Code: | 841202000 |
| Phone Number: | 8019643249 |
| Fax Number: | |
| NPI Enumeration Date: | 12/19/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 204C00000X |
| License Number: | 6053003-1204 |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | UT |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | Neuromusculoskeletal Medicine, Sports Medicine |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |