=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629043252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK CENTER FOOT AND ANKLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2006
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 671 E. RIVERPARK LANE STE 110
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-387-0900
-----------------------------------------------------
Fax | 208-345-5883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 671 E. RIVERPARK LANE STE 110
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-387-0900
-----------------------------------------------------
Fax | 208-345-5883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | ALYSSA BARBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-387-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | P142
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------