1700060902 NPI number — EVANSTON FAMILY FOOT CARE

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 1700060902 NPI number — EVANSTON FAMILY FOOT CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANSTON FAMILY FOOT CARE
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:
1700060902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 238
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82931-0238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-789-8997
Provider Business Mailing Address Fax Number:
307-789-2624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1565 HIGHWAY 150 SOUTH
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82930-5348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-789-8997
Provider Business Practice Location Address Fax Number:
307-789-2624
Provider Enumeration Date:
12/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEVITRE
Authorized Official First Name:
JASON
Authorized Official Middle Name:
CANNON
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
307-789-8997

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  127 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DD8254 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 1217844 00 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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