Healthcare Provider Details

I. General information

NPI: 1578093803
Provider Name (Legal Business Name): 505 FOOT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8019 LAVA REACH AVE NW STE A
ALBUQUERQUE NM
87120-6531
US

IV. Provider business mailing address

8019 LAVA REACH AVE NW STE A
ALBUQUERQUE NM
87120-6531
US

V. Phone/Fax

Practice location:
  • Phone: 505-210-2113
  • Fax: 505-962-0701
Mailing address:
  • Phone: 505-210-2113
  • Fax: 505-962-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number393
License Number StateNM

VIII. Authorized Official

Name: DR. BENJAMIN J HOCKIN
Title or Position: SOLE MBR
Credential: DPM
Phone: 505-210-2113