Provider Demographics
NPI:1932878030
Name:ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-253-6886
Mailing Address - Street 1:12523 S CREEK MEADOW RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7299
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:801-253-6888
Practice Address - Street 1:777 N 500 W STE 103
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1552
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:801-253-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-10
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty