Healthcare Provider Details

I. General information

NPI: 1407492671
Provider Name (Legal Business Name): PARK CITY PEDORTHICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E 1ST ST
MERRILL WI
54452-2508
US

IV. Provider business mailing address

902 E 1ST ST
MERRILL WI
54452-2508
US

V. Phone/Fax

Practice location:
  • Phone: 715-203-5730
  • Fax:
Mailing address:
  • Phone: 715-203-5730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. TASHA GLEASON
Title or Position: OWNER
Credential: C.PED
Phone: 715-203-5730