Provider Demographics
NPI:1033314125
Name:WEST VALLEY FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:WEST VALLEY FOOT & ANKLE CENTER
Other - Org Name:BOUNTIFUL FOOT & ANKLE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCMANAMA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-966-3556
Mailing Address - Street 1:3540 S 4000 W STE 480
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3285
Mailing Address - Country:US
Mailing Address - Phone:801-966-3556
Mailing Address - Fax:801-966-9839
Practice Address - Street 1:3540 S 4000 W STE 480
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-3285
Practice Address - Country:US
Practice Address - Phone:801-966-3556
Practice Address - Fax:801-966-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT781028940501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529741769004Medicaid
UT0615050001Medicare NSC
UT529741769004Medicaid