Healthcare Provider Details

I. General information

NPI: 1497689145
Provider Name (Legal Business Name): MODERN SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 N LA CHOLLA BLVD
TUCSON AZ
85741-2306
US

IV. Provider business mailing address

5590 W CHANDLER BLVD STE 4
CHANDLER AZ
85226-3744
US

V. Phone/Fax

Practice location:
  • Phone: 480-306-6627
  • Fax: 480-306-6696
Mailing address:
  • Phone: 480-306-6627
  • Fax: 480-306-6696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: SASHA FLYNN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 480-780-0467