1982883294 NPI number — SOLE TO SOUL PODIATRY LLC

Table of content: (NPI 1982883294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982883294 NPI number — SOLE TO SOUL PODIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLE TO SOUL PODIATRY 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:
1982883294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30236
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89173-0236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-228-1162
Provider Business Mailing Address Fax Number:
702-312-3932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3815 S JONES BLVD STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-228-1162
Provider Business Practice Location Address Fax Number:
702-312-3932
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
KELLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DPM
Authorized Official Telephone Number:
702-228-1162

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  9905 , 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: 002102010 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com