Provider Demographics
NPI:1932135415
Name:SWICK & JONES PEDORTHIC LAB, LLC
Entity Type:Organization
Organization Name:SWICK & JONES PEDORTHIC LAB, LLC
Other - Org Name:FOOT FOCUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWICKARD
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:937-256-3668
Mailing Address - Street 1:617 WATERVLIET AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2544
Mailing Address - Country:US
Mailing Address - Phone:937-256-3668
Mailing Address - Fax:937-256-1650
Practice Address - Street 1:617 WATERVLIET AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2544
Practice Address - Country:US
Practice Address - Phone:937-256-3668
Practice Address - Fax:937-256-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPED-0051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5727860001Medicare NSC