1255617072 NPI number — COOK FOOT & ANKLE SPECIALISTS

Table of content: (NPI 1255617072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255617072 NPI number — COOK FOOT & ANKLE SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COOK FOOT & ANKLE SPECIALISTS
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:
1255617072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 E 1400 N
Provider Second Line Business Mailing Address:
#B
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84341-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-752-9011
Provider Business Mailing Address Fax Number:
435-752-7159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 N 2000 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARR WEST
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84404-9219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-9011
Provider Business Practice Location Address Fax Number:
435-752-7159
Provider Enumeration Date:
10/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
435-752-9011

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  72759630501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 528741267005 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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