Healthcare Provider Details

I. General information

NPI: 1194938936
Provider Name (Legal Business Name): FOOT & ANKLE SURGICAL GROUP, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 ADAMS BLVD #104
BOULDER CITY NV
89005-2244
US

IV. Provider business mailing address

129 W LAKE MEAD PKWY #B-18
HENDERSON NV
89015-7055
US

V. Phone/Fax

Practice location:
  • Phone: 702-293-0151
  • Fax: 702-456-6688
Mailing address:
  • Phone: 702-564-8022
  • Fax: 702-558-1522

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number38610
License Number StateNV

VIII. Authorized Official

Name: DOUGLAS S STACEY
Title or Position: GENERAL PARTNER
Credential: DPM
Phone: 702-456-3668