Healthcare Provider Details

I. General information

NPI: 1699400762
Provider Name (Legal Business Name): ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 W 4100 S STE 150
WEST VALLEY UT
84120-5552
US

IV. Provider business mailing address

9980 S 300 W STE 310
SANDY UT
84070-3654
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-6886
  • Fax: 801-253-6888
Mailing address:
  • Phone: 801-253-6886
  • Fax: 385-900-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: RYAN ELLSWORTH
Title or Position: CEO
Credential:
Phone: 801-253-6886