Provider Demographics
NPI:1174020549
Name:MAKE YOURSELF, LLC
Entity Type:Organization
Organization Name:MAKE YOURSELF, LLC
Other - Org Name:SOLE SOURCE PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAMMERSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:765-244-7440
Mailing Address - Street 1:128 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2139
Mailing Address - Country:US
Mailing Address - Phone:765-244-7440
Mailing Address - Fax:
Practice Address - Street 1:128 W 5TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2139
Practice Address - Country:US
Practice Address - Phone:765-244-7440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000906A213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty