Healthcare Provider Details

I. General information

NPI: 1881908192
Provider Name (Legal Business Name): FOOTHILLS SPORTS MEDICINE & REHABILITATION - EAST VALLEY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 S VAL VISTA DR STE 107
MESA AZ
85204-7304
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 480-505-8140
  • Fax: 480-505-8145
Mailing address:
  • Phone: 480-706-1161
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

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