MEDICARE: ROCK CANYON FOOT AND ANKLE CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	678	CO

General Provider Information

NPI Number	:	1598924169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCK CANYON FOOT AND ANKLE CLINIC, LLC

Provider Business Mailing Address
First Line	:	3740 DACORO LN STE 105
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-2515
Country	:	US
Telephone Number	:	303-660-4115
Fax Number	:

Provider Business Practice Location Address
First Line	:	3740 DACORO LN
Second Line	:	SUITE 105
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-2503
Country	:	US
Telephone Number	:	303-660-4115
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JEREMY CADE CHRISTENSEN
Credential	:	D.P.M.
Telephone Number	:	303-660-4115

Provider Enumeration Date	:	06/08/2008
Last Update Date	:	04/06/2020

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