=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356168017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLSWORTH FOOT AND ANKLE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2024
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 N WESTWOOD BLVD
-----------------------------------------------------
City | PRICE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84501-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-253-6886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9980 S 300 W STE 300
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84070-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-253-6886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RYAN SCOTT ELLSWORTH
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 801-273-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------