1912053315 NPI number — FOOTWORKS LLC

Table of content: (NPI 1912053315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912053315 NPI number — FOOTWORKS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTWORKS 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:
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:
1912053315
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 ROUTE 70
Provider Second Line Business Mailing Address:
UNIT 15
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08055-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-953-6971
Provider Business Mailing Address Fax Number:
609-953-6972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 ROUTE 70
Provider Second Line Business Practice Location Address:
UNIT 15
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08055-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-953-6971
Provider Business Practice Location Address Fax Number:
609-953-6972
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KERR
Authorized Official First Name:
PETER
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PEDORTHIST
Authorized Official Telephone Number:
609-953-6971

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0006064000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0006064000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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