1881908192 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION - EAST VALLEY INC

Table of content: (NPI 1881908192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881908192 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION - EAST VALLEY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILLS SPORTS MEDICINE & REHABILITATION - EAST VALLEY INC
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:
FOOTHILLS SPORTS MEDICINE & REHABILITATION - GILBERT-MESA
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:
1881908192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2020
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
Provider Second Line Business Mailing Address:
SUITE 112
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:
1702 S VAL VISTA DR STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-7304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-505-8140
Provider Business Practice Location Address Fax Number:
480-505-8145
Provider Enumeration Date:
07/28/2010

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: 2251S0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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