Provider Demographics
NPI:1164610846
Name:FOOT FITNESS
Entity Type:Organization
Organization Name:FOOT FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:503-364-6006
Mailing Address - Street 1:PO BOX 7339
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0102
Mailing Address - Country:US
Mailing Address - Phone:503-364-6006
Mailing Address - Fax:503-364-6046
Practice Address - Street 1:258 SW 5TH ST STE 2
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2150
Practice Address - Country:US
Practice Address - Phone:541-923-2552
Practice Address - Fax:541-923-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier