1811180615 NPI number — CANYON FOOT & ANKLE SPECIALISTS PC

Table of content: (NPI 1811180615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811180615 NPI number — CANYON FOOT & ANKLE SPECIALISTS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON FOOT & ANKLE SPECIALISTS 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:
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:
1811180615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-733-0436
Provider Business Mailing Address Fax Number:
208-733-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
676 SHOUP AVE W
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-4615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-0436
Provider Business Practice Location Address Fax Number:
208-733-0438
Provider Enumeration Date:
08/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PILLING
Authorized Official First Name:
CORY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-733-0436

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  P-187 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807346000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1369188 . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: D08608980 . This is a "MEDICARE DME SUBITTER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: P-2428 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P2427 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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