Provider Demographics
NPI:1578830352
Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION -JCC, INC
Entity Type:Organization
Organization Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION -JCC, INC
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 1:15410 S MOUNTAIN PKWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3225 N CIVIC CENTER PLZ
Practice Address - Street 2:SUITE 10
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6919
Practice Address - Country:US
Practice Address - Phone:480-483-7121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty