Provider Demographics
NPI:1588011258
Name:MOBILE PODIATRY MANAGEMENT INC
Entity Type:Organization
Organization Name:MOBILE PODIATRY MANAGEMENT INC
Other - Org Name:KENNETH M. JARVIS DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:JARVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-810-1748
Mailing Address - Street 1:6127 TREVINO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-5926
Mailing Address - Country:US
Mailing Address - Phone:702-810-1748
Mailing Address - Fax:702-837-8292
Practice Address - Street 1:6127 TREVINO AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-5926
Practice Address - Country:US
Practice Address - Phone:702-810-1748
Practice Address - Fax:702-837-8292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETH M. JARVIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0108213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty