Healthcare Provider Details

I. General information

NPI: 1154860823
Provider Name (Legal Business Name): FINAL KICK ANKLE AND FOOT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E 4500 S SUITE 370
SALT LAKE CITY UT
84107-3906
US

IV. Provider business mailing address

348 E 4500 S SUITE 370
SALT LAKE CITY UT
84107-3906
US

V. Phone/Fax

Practice location:
  • Phone: 804-687-5191
  • Fax:
Mailing address:
  • Phone: 804-687-5191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1891082830
License Number StateUT

VIII. Authorized Official

Name: DR. SELINA SEKULIC
Title or Position: PRESIDENT
Credential: DPM
Phone: 804-687-5191