Provider Demographics
NPI:1922589258
Name:VALLEY FOOT & ANKLE
Entity Type:Organization
Organization Name:VALLEY FOOT & ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-375-6677
Mailing Address - Street 1:777 N 500 W STE 103
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1552
Mailing Address - Country:US
Mailing Address - Phone:801-375-6677
Mailing Address - Fax:
Practice Address - Street 1:777 N 500 W STE 103
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1552
Practice Address - Country:US
Practice Address - Phone:801-375-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367951-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty