=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578093803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 505 FOOT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 10/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8019 LAVA REACH AVE NW STE A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87120-6531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-210-2113
-----------------------------------------------------
Fax | 505-962-0701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8019 LAVA REACH AVE NW STE A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87120-6531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-210-2113
-----------------------------------------------------
Fax | 505-962-0701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | DR. BENJAMIN J HOCKIN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 505-210-2113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 393
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------