=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649006057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT SYSTEMS PLUS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2024
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1490 E FOREMASTER DR STE 140
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-4532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-219-7126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1490 E FOREMASTER DR STE 140
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-4532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-219-7126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ELIJAH HILLSTROM
-----------------------------------------------------
Credential | CPED
-----------------------------------------------------
Telephone | 702-219-7126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224L00000X
-----------------------------------------------------
Taxonomy Name | Pedorthist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------