Basic Information
| Provider Information | |||||||||
| NPI: | 1457304792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILLS SPORTS MEDICINE & ORTHOPAEDICS PHOENIX, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 539 E GLENDALE AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022413145 | ||||||||
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| Practice Location | |||||||||
| Address1: | 539 E GLENDALE AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022413145 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNOWDEN | ||||||||
| AuthorizedOfficialFirstName: | TANJA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6022413145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5009 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.