Provider Demographics
NPI:1376715797
Name:FOOTHILLS UROLOGY
Entity Type:Organization
Organization Name:FOOTHILLS UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:NICKLES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:864-855-6811
Mailing Address - Street 1:PO BOX 1793
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-1793
Mailing Address - Country:US
Mailing Address - Phone:864-855-6811
Mailing Address - Fax:864-855-6784
Practice Address - Street 1:403 HILLCREST DR
Practice Address - Street 2:SUITE A
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1207
Practice Address - Country:US
Practice Address - Phone:864-855-6811
Practice Address - Fax:864-855-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7514174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0270Medicaid
SC3217Medicare PIN