Healthcare Provider Details

I. General information

NPI: 1891037636
Provider Name (Legal Business Name): SALT LAKE CITY FOOT AND ANKLE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4578 S HIGHLAND DR ST. 380
SALT LAKE CITY UT
84117-4243
US

IV. Provider business mailing address

4578 S HIGHLAND DR ST. 380
SALT LAKE CITY UT
84117-4243
US

V. Phone/Fax

Practice location:
  • Phone: 801-274-9060
  • Fax: 801-274-2126
Mailing address:
  • Phone: 801-274-9060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number8425054-0501
License Number StateUT

VIII. Authorized Official

Name: CHRISTIAAN HORST GOEBEL
Title or Position: PODIATRIST/MANAGER
Credential: DPM
Phone: 801-274-9060