1538338884 NPI number — CC FOOT CLINIC PC

Table of content: (NPI 1538338884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538338884 NPI number — CC FOOT CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CC FOOT CLINIC PC
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:
CHERRY CREEK FOOT & ANKLE CLINIC
Provider Other Organization Name Type Code:
3
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:
1538338884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121 S ONEIDA ST
Provider Second Line Business Mailing Address:
STE 270
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80224-2549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-355-1695
Provider Business Mailing Address Fax Number:
303-355-1834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 S ONEIDA ST
Provider Second Line Business Practice Location Address:
STE 270
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80224-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-355-1695
Provider Business Practice Location Address Fax Number:
303-355-1834
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MELNICK
Authorized Official First Name:
LORRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
303-355-1695

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  308 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01003086 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com