1427442094 NPI number — HEELING SOLES PODIATRY 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 1427442094 NPI number — HEELING SOLES PODIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEELING SOLES PODIATRY 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:
1427442094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1217 WOODMERE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTAMONTE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32714-2851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2699 LEE RD STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32789-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-356-1258
Provider Business Practice Location Address Fax Number:
407-329-3294
Provider Enumeration Date:
03/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LUTTRELL
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
407-913-7173

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117852600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com