Basic Information
| Provider Information | |||||||||
| NPI: | 1649688730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILLS SPORTS MEDICINE & REHABILITATION - PRESCOTT VALLEY, INC | ||||||||
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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: | 4807067409 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 N WINDSONG DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2014 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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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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| AuthorizedOfficialCredential: | PT | ||||||||
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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.