Healthcare Provider Details

I. General information

NPI: 1942549795
Provider Name (Legal Business Name): ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12523 S CREEK MEADOW RD STE 105
RIVERTON UT
84065
US

IV. Provider business mailing address

12523 S CREEK MEADOW RD STE 105
RIVERTON UT
84065-7299
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-6886
  • Fax: 801-253-6888
Mailing address:
  • Phone: 801-253-6886
  • Fax: 801-253-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number8400193-0501
License Number StateUT

VIII. Authorized Official

Name: RYAN ELLSWORTH
Title or Position: OWNER, MANAGER
Credential: DPM
Phone: 801-550-0955