1033532130 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION - GOLD CANYON, LLC

Table of content: (NPI 1033532130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033532130 NPI number — FOOTHILLS SPORTS MEDICINE & REHABILITATION - GOLD CANYON, LLC

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1033532130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2016
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:
6788 S KINGS RANCH RD
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
GOLD CANYON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85118-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-982-1909
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2014

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)