Healthcare Provider Details

I. General information

NPI: 1811645484
Provider Name (Legal Business Name): FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY- BUCKEYE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S WATSON RD STE 104
BUCKEYE AZ
85326-6264
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-1161
  • Fax:
Mailing address:
  • Phone: 480-689-5534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL L BASTEN
Title or Position: DELEGATED OFFICIAL/CEO
Credential: DPT
Phone: 480-689-5515