Provider Demographics
NPI:1124414545
Name:ALTA RIDGE FOOT SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:ALTA RIDGE FOOT SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN BREDERODE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-766-7667
Mailing Address - Street 1:440 ALTAPASS HWY
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-3011
Mailing Address - Country:US
Mailing Address - Phone:828-766-7667
Mailing Address - Fax:828-766-7668
Practice Address - Street 1:2211 HIGHWAY 105
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-7813
Practice Address - Country:US
Practice Address - Phone:828-286-1948
Practice Address - Fax:828-286-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty