1659626265 NPI number — AT HOME PODIATRY, LLC

Table of content: (NPI 1659626265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659626265 NPI number — AT HOME PODIATRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AT HOME PODIATRY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AHP FOOT & WOUND CARE SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659626265
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9011 N MERIDIAN ST
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46260-5378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-218-4095
Provider Business Mailing Address Fax Number:
877-476-7125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9011 N MERIDIAN ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260-5378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-847-1558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MANN
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PODIATRIST
Authorized Official Telephone Number:
317-847-1558

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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