Provider Demographics
NPI:1083144406
Name:FAMILY FOOT & ANKLE
Entity Type:Organization
Organization Name:FAMILY FOOT & ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:515-205-5635
Mailing Address - Street 1:1332 E 630 S
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-4436
Mailing Address - Country:US
Mailing Address - Phone:515-205-5635
Mailing Address - Fax:
Practice Address - Street 1:491 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1654
Practice Address - Country:US
Practice Address - Phone:515-205-5635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY FOOT & ANKLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7054576-0501261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric