MEDICARE: FOOTHILLS SPORTS MEDICINE & REHABILITATION - SEVILLE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2251S0007X	Sports Physical Therapist
2	2251X0800X	Orthopedic Physical Therapist
3	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1053426767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHILLS SPORTS MEDICINE & REHABILITATION - SEVILLE, LLC

Provider Business Mailing Address
First Line	:	15410 S MOUNTAIN PKWY
Second Line	:	SUITE 112
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6691
Country	:	US
Telephone Number	:	480-689-5509
Fax Number	:	480-706-7997

Provider Business Practice Location Address
First Line	:	3336 E CHANDLER HEIGHTS RD
Second Line	:	SUITE 5-126
City	:	GILBERT
State	:	AZ
Zip	:	85297-4259
Country	:	US
Telephone Number	:	480-840-6125
Fax Number	:	480-840-6122

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL BASTEN
Credential	:
Telephone Number	:	480-689-5515

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	05/05/2022

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