1801209499 NPI number — FOUR CORNERS FOOT AND ANKLE P.C.

Table of content: (NPI 1801209499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801209499 NPI number — FOUR CORNERS FOOT AND ANKLE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR CORNERS FOOT AND ANKLE P.C.
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:
1801209499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1266 ESCALANTE DR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-259-5303
Provider Business Mailing Address Fax Number:
970-259-3510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 FARMINGTON AVE BLDG C
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-4550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-327-4044
Provider Business Practice Location Address Fax Number:
970-259-3510
Provider Enumeration Date:
06/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LAKE
Authorized Official First Name:
KAYSE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-259-5303

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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