1205921202 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION- TUCSON, LLC

Table of content: (NPI 1205921202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205921202 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION- TUCSON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILLS SPORTS MEDICINE & REHABILITATION- TUCSON, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROACTIVE PHYSICAL THERAPY - MARANA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205921202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15410 S MOUNTAIN PKWY STE 112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85044-6691
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-706-1161
Provider Business Mailing Address Fax Number:
480-706-7997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7575 W. TWIN PEAKS RD
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-744-6445
Provider Business Practice Location Address Fax Number:
520-742-5252
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BASTEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-689-5515

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AZ0460080 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com