1700060902 NPI number — EVANSTON FAMILY FOOT CARE

Table of content: (NPI 1700060902)

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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