Healthcare Provider Details

I. General information

NPI: 1235301466
Provider Name (Legal Business Name): THE DESERT SPORTS MEDICINE AND SHOULDER CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 E BROWN RD
MESA AZ
85205-4960
US

IV. Provider business mailing address

6130 EAST BROWN ROAD
MESA AZ
85205-4960
US

V. Phone/Fax

Practice location:
  • Phone: 480-807-3554
  • Fax: 480-807-8330
Mailing address:
  • Phone: 480-807-3554
  • Fax: 480-807-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31646
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number31646
License Number StateAZ

VIII. Authorized Official

Name: MR. DAVID PHILIP RICHARDS
Title or Position: PRESIDENT/PHYSICIAN
Credential: MD
Phone: 480-807-3554