1720092182 NPI number — ASSOCIATES FAMILY FOOT CARE, LLC

Table of content: (NPI 1720092182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720092182 NPI number — ASSOCIATES FAMILY FOOT CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATES FAMILY FOOT CARE, 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:
1720092182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GIRARD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44420-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-746-7660
Provider Business Mailing Address Fax Number:
330-746-8581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 JACOBS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44505-4908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-746-7660
Provider Business Practice Location Address Fax Number:
330-759-3988
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
CARMELITA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PODIATRIST/SURGEON
Authorized Official Telephone Number:
330-746-7660

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  36003113R , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2302547 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2453876 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2302501 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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