Provider Demographics
NPI:1891935821
Name:ALTA RIDGE FOOT SPECIALISTS PLLC
Entity Type:Organization
Organization Name:ALTA RIDGE FOOT SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:VAN BREDERODE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-766-7667
Mailing Address - Street 1:537 ALTAPASS HWY
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-3012
Mailing Address - Country:US
Mailing Address - Phone:828-766-7667
Mailing Address - Fax:
Practice Address - Street 1:537 ALTAPASS HWY
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-3012
Practice Address - Country:US
Practice Address - Phone:828-766-7667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC479261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890809TMedicaid
NCU86440Medicare UPIN
NC6200470001Medicare NSC