1760556104 NPI number — ADVANCED ANKLE AND FOOT CENTER, LLC

Table of content: (NPI 1083820468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760556104 NPI number — ADVANCED ANKLE AND FOOT CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED ANKLE AND FOOT CENTER, 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:
1760556104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REYNOLDSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43068-6554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-792-3668
Provider Business Mailing Address Fax Number:
614-792-7615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9759 FAIRWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWELL
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-792-3668
Provider Business Practice Location Address Fax Number:
614-792-7615
Provider Enumeration Date:
11/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANCOURT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER PODIATRIST
Authorized Official Telephone Number:
614-792-3668

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE8613 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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