Basic Information
| Provider Information | |||||||||
| NPI: | 1902375405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOTHILLS SPORTS MEDICINE & PHYSICAL THERAPY - GLENDALE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15410 S MOUNTAIN PKWY STE 112 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807061161 | ||||||||
| FaxNumber: | 4807067997 | ||||||||
| Practice Location | |||||||||
| Address1: | 19420 N 59TH AVE STE H830 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233029020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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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 | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.