Provider Demographics
NPI:1558784660
Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION - SUN CITY, LLC
Entity Type:Organization
Organization Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION - SUN CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-689-5515
Mailing Address - Street 1:4715 N 32ND ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3300
Mailing Address - Country:US
Mailing Address - Phone:480-689-5520
Mailing Address - Fax:480-706-7409
Practice Address - Street 1:13933 W GRAND AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2435
Practice Address - Country:US
Practice Address - Phone:623-474-3952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty