Provider Demographics
NPI:1801209499
Name:FOUR CORNERS FOOT AND ANKLE P.C.
Entity Type:Organization
Organization Name:FOUR CORNERS FOOT AND ANKLE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAYSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:970-259-5303
Mailing Address - Street 1:1266 ESCALANTE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301
Mailing Address - Country:US
Mailing Address - Phone:970-259-5303
Mailing Address - Fax:970-259-3510
Practice Address - Street 1:2700 FARMINGTON AVE BLDG C
Practice Address - Street 2:STE 1
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4550
Practice Address - Country:US
Practice Address - Phone:505-327-4044
Practice Address - Fax:970-259-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NM348332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty