Provider Demographics
NPI:1598924169
Name:ROCK CANYON FOOT AND ANKLE CLINIC, LLC
Entity Type:Organization
Organization Name:ROCK CANYON FOOT AND ANKLE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:CADE
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:303-660-4115
Mailing Address - Street 1:3740 DACORO LN STE 105
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-2515
Mailing Address - Country:US
Mailing Address - Phone:303-660-4115
Mailing Address - Fax:
Practice Address - Street 1:3740 DACORO LN
Practice Address - Street 2:SUITE 105
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-2503
Practice Address - Country:US
Practice Address - Phone:303-660-4115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-08
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO678213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4052Medicare UPIN
COCO400053Medicare UPIN
COCOB4052Medicare PIN
COCO400053Medicare PIN