Provider Demographics
NPI:1760757348
Name:CASCADE FOOT AND ANKLE PC
Entity Type:Organization
Organization Name:CASCADE FOOT AND ANKLE PC
Other - Org Name:JARED T CLEGG DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-373-2499
Mailing Address - Street 1:1937 N 1120 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1044
Mailing Address - Country:US
Mailing Address - Phone:801-373-2499
Mailing Address - Fax:801-373-5200
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:801-373-2499
Practice Address - Fax:801-373-5200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASCADE FOOT AND ANKLE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
005945749Medicare PIN