Healthcare Provider Details

I. General information

NPI: 1912683699
Provider Name (Legal Business Name): MODERN SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5590 W CHANDLER BLVD STE 4
CHANDLER AZ
85226-3744
US

IV. Provider business mailing address

5590 W CHANDLER BLVD STE 4
CHANDLER AZ
85226-3744
US

V. Phone/Fax

Practice location:
  • Phone: 480-306-6627
  • Fax: 480-306-6696
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA ADAMS
Title or Position: OWNER
Credential:
Phone: 480-306-6627