Healthcare Provider Details

I. General information

NPI: 1093374464
Provider Name (Legal Business Name): VALLEY FOOT & ANKLE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MARGARET LN STE A
GRASS VALLEY CA
95945-5261
US

IV. Provider business mailing address

104 MARGARET LN STE A
GRASS VALLEY CA
95945-5261
US

V. Phone/Fax

Practice location:
  • Phone: 530-648-1234
  • Fax: 530-648-1235
Mailing address:
  • Phone: 530-648-1234
  • Fax: 530-648-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: KELLY PAYNE
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-815-6862