Provider Demographics
NPI:1538321260
Name:CRESTWOOD FOOT CLINIC LLC
Entity Type:Organization
Organization Name:CRESTWOOD FOOT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:501-771-4785
Mailing Address - Street 1:2501 CRESTWOOD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-6864
Mailing Address - Country:US
Mailing Address - Phone:501-771-4785
Mailing Address - Fax:501-771-4787
Practice Address - Street 1:2501 CRESTWOOD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-771-4785
Practice Address - Fax:501-771-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR87335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161125716Medicaid
AR5659610001OtherDMERC