Basic Information
| Provider Information | |||||||||
| NPI: | 1881908192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOTHILLS SPORTS MEDICINE & REHABILITATION - EAST VALLEY INC | ||||||||
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| OtherOrganizationName: | FOOTHILLS SPORTS MEDICINE & REHABILITATION - GILBERT-MESA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1702 S VAL VISTA DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852047304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805058140 | ||||||||
| FaxNumber: | 4805058145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BASTEN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4806895515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
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.