Provider Demographics
NPI:1952660763
Name:ADVANCED PODIATRY OF SOUTHERN IDAHO, LLC
Entity Type:Organization
Organization Name:ADVANCED PODIATRY OF SOUTHERN IDAHO, LLC
Other - Org Name:ADVANCED FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAWNA
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOULDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-475-5239
Mailing Address - Street 1:6028 S RIDGELINE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-5239
Mailing Address - Fax:801-475-5286
Practice Address - Street 1:476 CHENEY DRIVE WEST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-731-6321
Practice Address - Fax:801-475-5286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8015238-0501213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty