1710001961 NPI number — SUN CITY FOOT CARE

Table of content: (NPI 1710001961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710001961 NPI number — SUN CITY FOOT CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUN CITY 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:
6
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:
1710001961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3320 NORTH BUFFALO DRIVE
Provider Second Line Business Mailing Address:
STE 107
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89129-7410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-256-8454
Provider Business Mailing Address Fax Number:
702-256-0387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3320 NORTH BUFFALO DRIVE
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89129-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-256-8454
Provider Business Practice Location Address Fax Number:
702-256-0387
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUBLER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-256-8454

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  9804 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CC1573 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1943324 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 002102006 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480029166 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 7208106 . This is a "AETNA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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