Healthcare Provider Details

I. General information

NPI: 1588716096
Provider Name (Legal Business Name): RAYSTOWN PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 MOORE ST
HUNTINGDON PA
16652-1826
US

IV. Provider business mailing address

1201 MOORE ST
HUNTINGDON PA
16652-1826
US

V. Phone/Fax

Practice location:
  • Phone: 814-643-1720
  • Fax: 814-643-4953
Mailing address:
  • Phone: 814-643-1720
  • Fax: 814-643-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. TAMMY E. CARLSON-LITTLE
Title or Position: OWNER
Credential: D.P.M.
Phone: 814-643-1720