Provider Demographics
NPI:1649688730
Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION - PRESCOTT VALLEY, INC
Entity type:Organization
Organization Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION - PRESCOTT VALLEY, 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:PT
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:480-706-1161
Mailing Address - Fax:480-706-7409
Practice Address - Street 1:3033 N WINDSONG DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2290
Practice Address - Country:US
Practice Address - Phone:480-706-1161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-01
Last Update Date:2014-08-15
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