MEDICARE: JUAN TABO FOOT HEALTH CENTER, PC

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	213E00000X	Podiatrist	145	NM

General Provider Information

NPI Number	:	1699060202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUAN TABO FOOT HEALTH CENTER, PC

Provider Business Mailing Address
First Line	:	1925 JUAN TABO BLVD NE
Second Line	:	SUITE D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3366
Country	:	US
Telephone Number	:	505-293-6290
Fax Number	:	505-292-3014

Provider Business Practice Location Address
First Line	:	1925 JUAN TABO BLVD NE
Second Line	:	SUITE D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3366
Country	:	US
Telephone Number	:	505-293-6290
Fax Number	:	505-292-3014

Authorized Official
Title or Position	:	PODIATRIST
Name	:	DR. RICHARD A WEINSTEIN
Credential	:	DPM
Telephone Number	:	505-293-6290

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	06/10/2011

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