1578622502 NPI number — SAN JUAN FOOT AND ANKLE CENTER

Table of content: (NPI 1578622502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578622502 NPI number — SAN JUAN FOOT AND ANKLE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JUAN FOOT AND ANKLE CENTER
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:
1578622502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80308-4150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-240-3338
Provider Business Mailing Address Fax Number:
970-240-1541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 E MAIN ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTROSE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81401-3848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-240-3338
Provider Business Practice Location Address Fax Number:
970-240-1541
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
970-240-3338

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  628 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 94132526 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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