Provider Demographics
NPI:1407492671
Name:PARK CITY PEDORTHICS
Entity Type:Organization
Organization Name:PARK CITY PEDORTHICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:715-203-5730
Mailing Address - Street 1:902 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-2508
Mailing Address - Country:US
Mailing Address - Phone:715-203-5730
Mailing Address - Fax:
Practice Address - Street 1:902 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2508
Practice Address - Country:US
Practice Address - Phone:715-203-5730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty