Healthcare Provider Details

I. General information

NPI: 1285218750
Provider Name (Legal Business Name): ON THE MOVE PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19636 N 27TH AVE STE 207
PHOENIX AZ
85027-4015
US

IV. Provider business mailing address

19636 N 27TH AVE STE 301
PHOENIX AZ
85027-4016
US

V. Phone/Fax

Practice location:
  • Phone: 602-993-2700
  • Fax:
Mailing address:
  • Phone: 602-993-2700
  • Fax: 602-993-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELLY FERRULLI
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-993-2700