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
1	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1568051092
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	:	401 E JEFFERSON ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2438
Country	:	US
Telephone Number	:	602-343-6310
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALIST
Name	:	EILEEN AHERN
Credential	:
Telephone Number	:	800-954-1800

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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