Healthcare Provider Details

I. General information

NPI: 1609144989
Provider Name (Legal Business Name): COLLINS FOOT & ANKLE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 E 3900 S SUITE 100
SALT LAKE CITY UT
84124-1476
US

IV. Provider business mailing address

1377 E 3900 S SUITE 100
SALT LAKE CITY UT
84124-1476
US

V. Phone/Fax

Practice location:
  • Phone: 801-273-0100
  • Fax:
Mailing address:
  • Phone: 801-273-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number105502-0501
License Number StateUT

VIII. Authorized Official

Name: DR. TYLER LEWIS COLLINS
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 801-273-0100