Basic Information
| Provider Information | |||||||||
| NPI: | 1033532130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILLS SPORTS MEDICINE & REHABILITATION - GOLD CANYON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15410 S MOUNTAIN PKWY | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Practice Location | |||||||||
| Address1: | 6788 S KINGS RANCH RD | ||||||||
| Address2: | STE 4 | ||||||||
| City: | GOLD CANYON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851182931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809821909 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | BASTEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4806895515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.