1063518132 NPI number — ADVANCED FOOT CLINIC, PC

Table of content: (NPI 1063518132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063518132 NPI number — ADVANCED FOOT CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOT CLINIC, PC
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:
Provider Other Organization Name Type Code:
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:
1063518132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERWOOD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97140-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-612-4040
Provider Business Mailing Address Fax Number:
503-625-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6464 SW BORLAND RD STE B3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUALATIN
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97062-8855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-612-4040
Provider Business Practice Location Address Fax Number:
503-625-8638
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ARABSHAHI
Authorized Official First Name:
AZADEH
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR/MANAGER
Authorized Official Telephone Number:
503-391-0688

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DP00296 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: R116947 . This is a "MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 5738490002 . This is a "MEDICARE DME" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 480034478 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 158911 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480034478 . This is a "PALMETTO GBA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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