Provider Demographics
NPI:1497328330
Name:SOUTHWEST FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:SOUTHWEST FOOT AND ANKLE CENTER LLC
Other - Org Name:SOUTHWEST FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETRINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:425-277-3668
Mailing Address - Street 1:4300 TALBOT RD S STE 102
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-277-3668
Mailing Address - Fax:425-277-0732
Practice Address - Street 1:9343 E SHEA BLVD STE B-130
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6802
Practice Address - Country:US
Practice Address - Phone:425-277-3668
Practice Address - Fax:425-277-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8146570001OtherNORIDIAN