Provider Demographics
NPI:1912283045
Name:FRONT RANGE FOOT AND ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:FRONT RANGE FOOT AND ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:720-670-0544
Mailing Address - Street 1:10259 SOUTH PARKER RD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134
Mailing Address - Country:US
Mailing Address - Phone:720-670-0544
Mailing Address - Fax:720-253-0794
Practice Address - Street 1:10259 SOUTH PARKER RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134
Practice Address - Country:US
Practice Address - Phone:720-670-0544
Practice Address - Fax:720-253-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO650213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6910950001OtherDMERC PTAN