Provider Demographics
NPI:1407507312
Name:ELLSWORTH FOOT AND ANKLE
Entity Type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-253-6886
Mailing Address - Street 1:9980 S 300 W STE 310
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:
Practice Address - Street 1:770 S HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631-5033
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty