1124571096 NPI number — THE FOOT AND ANKLE CLINIC OF WEST MONROE, LLC

Table of content: (NPI 1124571096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124571096 NPI number — THE FOOT AND ANKLE CLINIC OF WEST MONROE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FOOT AND ANKLE CLINIC OF WEST MONROE, 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:
1124571096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2269 ARKANSAS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-7818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-397-1574
Provider Business Mailing Address Fax Number:
318-397-1672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5745 HWY 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROWVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-397-1574
Provider Business Practice Location Address Fax Number:
318-397-1672
Provider Enumeration Date:
07/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
LUKE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PODIATRIC SURGEON
Authorized Official Telephone Number:
318-397-1574

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  DPM.200054 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2372726 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457772774 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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