1497364780 NPI number — RIO GRANDE FOOT & ANKLE SPECIALISTS LLC

Table of content: (NPI 1497364780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497364780 NPI number — RIO GRANDE FOOT & ANKLE SPECIALISTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIO GRANDE FOOT & ANKLE SPECIALISTS 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:
RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
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:
1497364780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 540610
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N SALT LAKE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84054-0610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-505-0821
Provider Business Mailing Address Fax Number:
801-505-0803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 GALISTEO ST STE K-2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-2143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-395-9575
Provider Business Practice Location Address Fax Number:
877-540-1253
Provider Enumeration Date:
07/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DEITHLOFF
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
DPM/OWNER
Authorized Official Telephone Number:
505-395-9575

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: POD401 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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