=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639575046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWENSON FOOT & ANKLE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2014
-----------------------------------------------------
Last Update Date | 11/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5380 S RAINBOW BLVD STE 318
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-873-3556
-----------------------------------------------------
Fax | 702-871-4190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5380 S RAINBOW BLVD STE 318
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-873-3556
-----------------------------------------------------
Fax | 702-871-4190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GRANT SWENSON
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 702-873-3556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 2000
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------