Healthcare Provider Details

I. General information

NPI: 1003373507
Provider Name (Legal Business Name): SELLERSSPORTSMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 E BASELINE RD STE C2
TEMPE AZ
85283-1528
US

IV. Provider business mailing address

1840 E BASELINE RD STE C2
TEMPE AZ
85283-1528
US

V. Phone/Fax

Practice location:
  • Phone: 480-751-3777
  • Fax: 480-751-3785
Mailing address:
  • Phone: 480-751-3777
  • Fax: 480-751-3785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOEL S SELLERS
Title or Position: PHYSICIAN
Credential: DO
Phone: 480-426-2667