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NPI Code Detail

MEDICARE: MOUNTAINSIDE FITNESS ACQUISITIONS, LLC

MEDICARE: MOUNTAINSIDE FITNESS ACQUISITIONS, LLC
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
12081S0010XSports Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number : 1528656204
Entity Type Code : Organization
Provider Name (Legal Business Name) : MOUNTAINSIDE FITNESS ACQUISITIONS, LLC
Provider Business Mailing Address
First Line : 7135 E CAMELBACK RD
Second Line :
City : SCOTTSDALE
State : AZ
Zip : 85251-1262
Country : US
Telephone Number : 480-706-8963
Fax Number :
Provider Business Practice Location Address
First Line : 2655 W CAREFREE HWY
Second Line :
City : PHOENIX
State : AZ
Zip : 85085-8862
Country : US
Telephone Number : 623-587-9977
Fax Number :
Authorized Official
Title or Position : CREDENTALIST
Name : EILEEN AHERN
Credential :
Telephone Number : 800-954-1800
Provider Enumeration Date : 01/07/2021
Last Update Date : 01/07/2021

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