Provider Demographics
NPI:1891037636
Name:SALT LAKE CITY FOOT AND ANKLE CLINIC, LLC
Entity Type:Organization
Organization Name:SALT LAKE CITY FOOT AND ANKLE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAAN
Authorized Official - Middle Name:HORST
Authorized Official - Last Name:GOEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-274-9060
Mailing Address - Street 1:4578 S HIGHLAND DR
Mailing Address - Street 2:ST. 380
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4243
Mailing Address - Country:US
Mailing Address - Phone:801-274-9060
Mailing Address - Fax:
Practice Address - Street 1:4578 S HIGHLAND DR
Practice Address - Street 2:ST. 380
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4243
Practice Address - Country:US
Practice Address - Phone:801-274-9060
Practice Address - Fax:801-274-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8425054-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6810920001Medicare NSC