=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679938294
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT AND ANKLE CLINIC OF SPOKANE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2015
-----------------------------------------------------
Last Update Date | 12/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8944 N HESS ST # A
-----------------------------------------------------
City | HAYDEN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83835-9183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-762-0909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9116 E SPRAGUE AVE # 278
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99206-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-928-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER- DOCTOR
-----------------------------------------------------
Name | DR. JACQUELINE MENDOZA BABOL
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 509-928-8181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | P218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BN1400X
-----------------------------------------------------
Taxonomy Name | Nursing Facility Supplies (DME)
-----------------------------------------------------
License Number | P218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | P218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | P218
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------