1275667958 NPI number — THE FOOT AND ANKLE CLINIC LLC

Table of content: (NPI 1275667958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275667958 NPI number — THE FOOT AND ANKLE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FOOT AND ANKLE CLINIC 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:
1275667958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44708-0690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-833-5692
Provider Business Mailing Address Fax Number:
330-833-6085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 W 150TH ST
Provider Second Line Business Practice Location Address:
220
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44135-1362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-227-2194
Provider Business Practice Location Address Fax Number:
216-227-2196
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOVACH
Authorized Official First Name:
KRISTINA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
216-227-2194

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  36002928 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2035158 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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