Provider Demographics
NPI:1982883294
Name:SOLE TO SOUL PODIATRY LLC
Entity Type:Organization
Organization Name:SOLE TO SOUL PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-228-1162
Mailing Address - Street 1:PO BOX 30236
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-0236
Mailing Address - Country:US
Mailing Address - Phone:702-228-1162
Mailing Address - Fax:702-312-3932
Practice Address - Street 1:3815 S JONES BLVD STE 6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:702-228-1162
Practice Address - Fax:702-312-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9905213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002102010Medicaid
NV5384790001Medicare NSC