Provider Demographics
NPI:1083261697
Name:TREASURE VALLEY FOOT AND ANKLE
Entity Type:Organization
Organization Name:TREASURE VALLEY FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-546-9548
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0268
Mailing Address - Country:US
Mailing Address - Phone:208-516-3617
Mailing Address - Fax:208-314-2029
Practice Address - Street 1:3120 W BELLTOWER DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7744
Practice Address - Country:US
Practice Address - Phone:208-516-3617
Practice Address - Fax:208-314-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty