Healthcare Provider Details

I. General information

NPI: 1710199278
Provider Name (Legal Business Name): FOOTHILLS SPORTS MEDICINE & REHABILITATION - GRAYHAWK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21811 N SCOTTSDALE RD SUTE 120
SCOTTSDALE AZ
85255-7441
US

IV. Provider business mailing address

21811 N SCOTTSDALE RD SUTE 120
SCOTTSDALE AZ
85255-7441
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-1161
  • Fax: 480-706-7997
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: MR. MICHAEL BASTEN
Title or Position: OWNER
Credential: PT
Phone: 480-689-5515