Healthcare Provider Details

I. General information

NPI: 1568072387
Provider Name (Legal Business Name): MODERN SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 E WARNER RD STE 121
TEMPE AZ
85284-3445
US

IV. Provider business mailing address

1840 E WARNER RD STE 121
TEMPE AZ
85284-3445
US

V. Phone/Fax

Practice location:
  • Phone: 480-878-4806
  • Fax: 480-840-1672
Mailing address:
  • Phone: 480-878-4806
  • Fax: 480-840-1672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA ADAMS
Title or Position: DIRECTOR OF REVENUE
Credential:
Phone: 480-306-6627