Provider Demographics
NPI:1356416770
Name:ROCKY MOUNTAIN FOOT AND ANKLE CLINIC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN FOOT AND ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ALLAN
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 105
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5032
Mailing Address - Country:US
Mailing Address - Phone:801-375-6677
Mailing Address - Fax:801-375-0346
Practice Address - Street 1:777 N 500 W
Practice Address - Street 2:SUITE 105
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1541
Practice Address - Country:US
Practice Address - Phone:801-375-6677
Practice Address - Fax:801-375-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367951213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529084511004Medicaid
UT4385650001Medicare NSC
UTU75122Medicare UPIN
UT000055890Medicare PIN