Provider Demographics
NPI:1295001683
Name:CASCADE FOOT AND ANKLE CLINIC PC
Entity type:Organization
Organization Name:CASCADE FOOT AND ANKLE CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-373-2499
Mailing Address - Street 1:1973 NORTH STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5711
Mailing Address - Country:US
Mailing Address - Phone:801-373-2499
Mailing Address - Fax:801-373-5200
Practice Address - Street 1:1973 NORTH STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5711
Practice Address - Country:US
Practice Address - Phone:801-373-2499
Practice Address - Fax:801-373-5200
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASCADE FOOT AND ANKLE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-29
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5203910001Medicare NSC
UTU000078170Medicare PIN