Provider Demographics
NPI:1609296326
Name:MAGIC VALLEY FOOT AND ANKLE SPECIALISTS PLLC
Entity Type:Organization
Organization Name:MAGIC VALLEY FOOT AND ANKLE SPECIALISTS PLLC
Other - Org Name:CALEB EDWIN ROBERTS SOLE MBR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-709-1700
Mailing Address - Street 1:496 SHOUP AVE W
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5834
Mailing Address - Country:US
Mailing Address - Phone:208-709-1700
Mailing Address - Fax:
Practice Address - Street 1:496 SHOUP AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5834
Practice Address - Country:US
Practice Address - Phone:208-709-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCS35833213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty