Provider Demographics
NPI:1083954804
Name:SIERRA VISTA FAMILY FOOTCARE PC
Entity Type:Organization
Organization Name:SIERRA VISTA FAMILY FOOTCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:520-803-0509
Mailing Address - Street 1:PO BOX 3345
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85636-3345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4235 S MOHAVE DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-8429
Practice Address - Country:US
Practice Address - Phone:520-803-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0430213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty