Basic Information
| Provider Information | |||||||||
| NPI: | 1316092117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILLS SPORTS MEDICINE & REHABILITATION - OCOTILLO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 S ALMA SCHOOL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.