1922304682 NPI number — FOOT AND ANKLE CLINIC, PC

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 1922304682 NPI number — FOOT AND ANKLE CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE CLINIC, 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:
1922304682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1502 PIERCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51105-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-255-0502
Provider Business Mailing Address Fax Number:
712-258-9977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 N 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAIR
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68008-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-426-1239
Provider Business Practice Location Address Fax Number:
402-426-1191
Provider Enumeration Date:
01/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
UNG
Authorized Official First Name:
KHAM
Authorized Official Middle Name:
VAY
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
712-255-0502

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  00505 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0476317 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800690 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800700 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800454 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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