1932686334 NPI number — KINETIC FOOT AND ANKLE, LLC

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 1932686334 NPI number — KINETIC FOOT AND ANKLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINETIC FOOT AND ANKLE, 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:
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:
1932686334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE FALLS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07424-1535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
862-520-8895
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 MCBRIDE AVE UNIT 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODLAND PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07424-2535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
862-520-8895
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VISPERAS
Authorized Official First Name:
RICO MIGUEL
Authorized Official Middle Name:
ALMAZAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
862-520-8895

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  25MD00323600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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