=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437416146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO SPORTS PERFORMANCE & REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 09/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8630 E VIA DE VENTURA SUITE #101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-433-4760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8630 E VIA DE VENTURA SUITE #101
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-433-4760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | TROY K MEINERS
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 480-433-4760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 7369
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------