Provider Demographics
NPI:1497364780
Name:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Entity Type:Organization
Organization Name:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Other - Org Name:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DEITHLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-395-9575
Mailing Address - Street 1:PO BOX 540610
Mailing Address - Street 2:
Mailing Address - City:N SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0610
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:2019 GALISTEO ST STE K-2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-395-9575
Practice Address - Fax:877-540-1253
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-23
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPOD401OtherMEDICAL LICENSE