Provider Demographics
NPI:1316032451
Name:LONGVIEW FOOT & ANKLE CLINIC
Entity Type:Organization
Organization Name:LONGVIEW FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCLANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-575-9161
Mailing Address - Street 1:725 NW 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1301
Mailing Address - Country:US
Mailing Address - Phone:503-243-2699
Mailing Address - Fax:503-243-2698
Practice Address - Street 1:783 COMMERCE AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-575-9161
Practice Address - Fax:360-575-9306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000596213E00000X
ORDP00317213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA129510OtherL&I
WAMC5942OtherREGENCE RIDER
WA1101682Medicaid
WA8397218OtherDMERC DSHS
WA8397218OtherDMERC DSHS
WA129510OtherL&I
WAU66176Medicare UPIN