1295030971 NPI number — FAMILY FOOT CLINIC INC

Table of content: (NPI 1295030971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295030971 NPI number — FAMILY FOOT CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FOOT CLINIC INC
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:
1295030971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 14TH AVE SE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-3718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-845-0564
Provider Business Mailing Address Fax Number:
253-770-8482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 14TH AVE SE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-845-0564
Provider Business Practice Location Address Fax Number:
253-770-8482
Provider Enumeration Date:
01/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-845-0564

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  PO 60188334 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1427077114 . This is a "INDIVIDUAL NPI NUMBER" identifier . This identifiers is of the category "OTHER".




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