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General NPI Number Information
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NPI Number | 1083261697
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Entity Type | Organization
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Legal Business Name | TREASURE VALLEY FOOT AND ANKLE
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Dates
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Enumeration Date | 08/20/2019
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 3120 W BELLTOWER DR STE 100
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City | MERIDIAN
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State | ID
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Zip | 83646-7744
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Country | US
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Telephone | 208-516-3617
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Fax | 208-314-2029
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Provider Business Mailing Address
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Address Line | PO BOX 268
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City | BOUNTIFUL
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State | UT
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Zip | 84011-0268
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Country | US
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Telephone | 208-516-3617
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Fax | 208-314-2029
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Authorized Official
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Title or Position | PRESIDENT
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Name | CLARK A JOHNSON
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Credential |
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Telephone | 208-546-9548
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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