Provider Demographics
NPI:1982809703
Name:WEST VALLEY FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:WEST VALLEY FOOT & ANKLE CENTER
Other - Org Name:BOUNTIFUL FOOT & ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCMANAMA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-966-3556
Mailing Address - Street 1:513 W 2600 S STE 513
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7717
Mailing Address - Country:US
Mailing Address - Phone:801-292-9202
Mailing Address - Fax:801-966-9839
Practice Address - Street 1:513 W 2600 S STE 513
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7717
Practice Address - Country:US
Practice Address - Phone:801-292-9202
Practice Address - Fax:801-966-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT781028940501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529741769004Medicaid
UT000001465Medicare ID - Type Unspecified