=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356501035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILL COUNTRY ADVANCED FOOT AND ANKLE CENTER, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2008
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10201 HIGHWAY 16
-----------------------------------------------------
City | COMANCHE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76442-4462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-693-8144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | MARBLE FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78654-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-693-8144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | BLAKE JAMAIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 830-693-8144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 1744, 1745
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------