Provider Demographics
NPI:1407042583
Name:FOOTHILL SPORTS MEDICINE
Entity Type:Organization
Organization Name:FOOTHILL SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:CERVANTEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-450-6427
Mailing Address - Street 1:2645 PARLEYS WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1636
Mailing Address - Country:US
Mailing Address - Phone:801-450-6427
Mailing Address - Fax:801-484-2828
Practice Address - Street 1:2645 PARLEYS WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1636
Practice Address - Country:US
Practice Address - Phone:801-450-6427
Practice Address - Fax:801-484-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy