Healthcare Provider Details

I. General information

NPI: 1871298000
Provider Name (Legal Business Name): MODERN SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8240 W CACTUS RD STE 100
PEORIA AZ
85381-5231
US

IV. Provider business mailing address

8240 W CACTUS RD STE 100
PEORIA AZ
85381-5231
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
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