1104204775 NPI number — HIGH DESERT FOOT & ANKLE CLINIC A

Table of content: MRS. ALICIA ELAINE MCCURDY RN (NPI 1184898108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104204775 NPI number — HIGH DESERT FOOT & ANKLE CLINIC A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGH DESERT FOOT & ANKLE CLINIC A
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:
1104204775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15366 11TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92395-3726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-951-1234
Provider Business Mailing Address Fax Number:
760-951-1611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15366 11TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-3726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-951-1234
Provider Business Practice Location Address Fax Number:
760-951-1611
Provider Enumeration Date:
05/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLMANN
Authorized Official First Name:
WONSIK
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER/PODIATRIST
Authorized Official Telephone Number:
760-951-1234

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E3966 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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