Healthcare Provider Details

I. General information

NPI: 1740290865
Provider Name (Legal Business Name): FOOTHILL PODIATRY CLINIC OF GRASS VALLEY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CATHERINE LN STE F
GRASS VALLEY CA
95945-5756
US

IV. Provider business mailing address

152 CATHERINE LN STE F
GRASS VALLEY CA
95945-5756
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-7200
  • Fax: 530-477-1246
Mailing address:
  • Phone: 530-477-7200
  • Fax: 530-477-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH CONNIE COOK
Title or Position: BILLER
Credential:
Phone: 530-477-7200