1598776833 NPI number — FLEETWOOD FOOTCARE CENTER, PC

Table of content: (NPI 1598776833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598776833 NPI number — FLEETWOOD FOOTCARE CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLEETWOOD FOOTCARE CENTER, 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:
FLEETWOOD FOOT AND ANKLE CENTER
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:
1598776833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/05/2008
NPI Reactivation Date:
06/04/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 LENHART RD
Provider Second Line Business Mailing Address:
PO BOX 425
Provider Business Mailing Address City Name:
FLEETWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19522-0425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-944-6537
Provider Business Mailing Address Fax Number:
610-944-8152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 LENHART RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEETWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19522-8613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-944-6537
Provider Business Practice Location Address Fax Number:
610-944-8152
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GEIST
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
610-944-6537

Provider Taxonomy Codes

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

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

  • Identifier: 02340700 . This is a "CAPITAL BLUE CMS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1016356050001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02340700 . This is a "BC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1602963 . This is a "BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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