Healthcare Provider Details

I. General information

NPI: 1174829584
Provider Name (Legal Business Name): SPORTS AND FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9316 E RAINTREE DR SUITE 140
SCOTTSDALE AZ
85260-3005
US

IV. Provider business mailing address

9316 E RAINTREE DR SUITE 140
SCOTTSDALE AZ
85260-3005
US

V. Phone/Fax

Practice location:
  • Phone: 480-614-2322
  • Fax: 480-614-2522
Mailing address:
  • Phone: 480-614-2322
  • Fax: 480-614-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6058
License Number StateAZ

VIII. Authorized Official

Name: DR. SIMON MARK BILLINGHAM
Title or Position: PRESIDENT
Credential: D.C.
Phone: 480-614-2322