Healthcare Provider Details

I. General information

NPI: 1144629916
Provider Name (Legal Business Name): ARIZONA SPORTS MEDICINE CENTER PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8630 E VIA DE VENTURA SUITE 201
SCOTTSDALE AZ
85258-3326
US

IV. Provider business mailing address

8630 E VIA DE VENTURA SUITE 201
SCOTTSDALE AZ
85258-3326
US

V. Phone/Fax

Practice location:
  • Phone: 480-558-3744
  • Fax: 480-558-3801
Mailing address:
  • Phone: 480-558-3744
  • Fax: 480-558-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. JASON R MOORE
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 480-889-1580