Provider Demographics
NPI:1982076832
Name:TABLE MOUNTAIN FOOT AND ANKLE CLINIC PC
Entity Type:Organization
Organization Name:TABLE MOUNTAIN FOOT AND ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTI
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:303-422-6043
Mailing Address - Street 1:3555 LUTHERAN PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 UNION BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1810
Practice Address - Country:US
Practice Address - Phone:303-985-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TABLE MOUNTAIN FOOT AND ANKLE CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO547213E00000X
CO544213ES0103X
CO324213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty