Provider Demographics
NPI:1255509154
Name:TOOELE FOOT & ANKLE CLINIC, INC.
Entity Type:Organization
Organization Name:TOOELE FOOT & ANKLE CLINIC, INC.
Other - Org Name:TOOELE FOOT CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:HALLADAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:435-882-0711
Mailing Address - Street 1:2356 N 400 E
Mailing Address - Street 2:STE 104
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3409
Mailing Address - Country:US
Mailing Address - Phone:435-882-0711
Mailing Address - Fax:435-882-1778
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:STE 104
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:435-882-0711
Practice Address - Fax:435-882-1778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103966-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0994190001Medicare NSC
UT000001706Medicare PIN