Healthcare Provider Details

I. General information

NPI: 1700305596
Provider Name (Legal Business Name): FOOTHILLS SPORTS MEDICINE & PHYSICAL THERAPY - STETSON VILLAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 W HAPPY VALLEY RD STE 147149
GLENDALE AZ
85310-3280
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 623-322-8925
  • Fax: 623-444-8336
Mailing address:
  • Phone: 480-706-1161
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BASTEN
Title or Position: OWNER
Credential:
Phone: 480-689-5515