Healthcare Provider Details

I. General information

NPI: 1659688380
Provider Name (Legal Business Name): JLA SENIOR FOOTCARE NM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVE I
LOVINGTON NM
88260-5002
US

IV. Provider business mailing address

4870 S ASPEN CT
CANFIELD OH
44406-8469
US

V. Phone/Fax

Practice location:
  • Phone: 575-396-5212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number331
License Number StateNM

VIII. Authorized Official

Name: ANTHONY INNOCENZI
Title or Position: OWNER
Credential:
Phone: 330-702-0978