Provider Demographics
NPI:1780713552
Name:PODIATRY CARE CENTER OF ONTARIO, LLC
Entity type:Organization
Organization Name:PODIATRY CARE CENTER OF ONTARIO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-463-7732
Mailing Address - Street 1:1511 W BONNEVILLE CT
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-9749
Mailing Address - Country:US
Mailing Address - Phone:208-463-7732
Mailing Address - Fax:541-889-4736
Practice Address - Street 1:2449 SW 4TH AVE
Practice Address - Street 2:STE 203
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1859
Practice Address - Country:US
Practice Address - Phone:541-889-8637
Practice Address - Fax:541-889-4736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00359213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1351149Medicare PIN
OR132080Medicare PIN
ORV04432Medicare UPIN
OR132078Medicare PIN