Healthcare Provider Details

I. General information

NPI: 1639767304
Provider Name (Legal Business Name): MOUNTAINSIDE FITNESS ACQUISITIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 E RAY RD
PHOENIX AZ
85044-6402
US

IV. Provider business mailing address

7135 E CAMELBACK RD
SCOTTSDALE AZ
85251-1262
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-2574
  • Fax:
Mailing address:
  • Phone: 480-706-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: EILEEN AHERN
Title or Position: CREDENTIALIST
Credential:
Phone: 800-954-1800