1689603805 NPI number — LIBERTY DAYTON FOOT & ANKLE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689603805 NPI number — LIBERTY DAYTON FOOT & ANKLE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY DAYTON FOOT & ANKLE CENTER
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:
LIBERTY DAYTON FOOT & 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:
1689603805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77575-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-444-4114
Provider Business Mailing Address Fax Number:
281-453-1269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77575-4705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-336-2633
Provider Business Practice Location Address Fax Number:
936-336-6031
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACTAVISH
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
936-336-2633

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  506 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG6815 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00J24P . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 121574103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 199497201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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