Provider Demographics
NPI:1902025638
Name:LONG TRAIL PODIATRY PLLC
Entity Type:Organization
Organization Name:LONG TRAIL PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:802-359-4335
Mailing Address - Street 1:2456 CHRISTIAN ST
Mailing Address - Street 2:SUITE L2
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9856
Mailing Address - Country:US
Mailing Address - Phone:802-359-4335
Mailing Address - Fax:802-359-4336
Practice Address - Street 1:2456 CHRISTIAN ST
Practice Address - Street 2:SUITE L2
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9856
Practice Address - Country:US
Practice Address - Phone:802-359-4335
Practice Address - Fax:802-359-4336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTL0018421261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric