1275783862 NPI number — COMPLETE FOOT CARE OF THE FINGER LAKES, PLLC

Table of content: (NPI 1275783862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275783862 NPI number — COMPLETE FOOT CARE OF THE FINGER LAKES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPLETE FOOT CARE OF THE FINGER LAKES, PLLC
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:
1275783862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 WEST SHORE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14513-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-331-5059
Provider Business Mailing Address Fax Number:
315-331-5482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 WEST SHORE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14513-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-331-5059
Provider Business Practice Location Address Fax Number:
315-331-5482
Provider Enumeration Date:
09/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
O'NEILL
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Z.
Authorized Official Title or Position:
OWNER/SOLE PROPRIETOR
Authorized Official Telephone Number:
315-331-5059

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  NOO5548 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106106EQ . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01955462 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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