MEDICARE: MOBILE PODIATRY MANAGEMENT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist	0108	NV

General Provider Information

NPI Number	:	1588011258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE PODIATRY MANAGEMENT INC

Provider Business Mailing Address
First Line	:	6127 TREVINO AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-5926
Country	:	US
Telephone Number	:	702-810-1748
Fax Number	:	702-837-8292

Provider Business Practice Location Address
First Line	:	6127 TREVINO AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-5926
Country	:	US
Telephone Number	:	702-810-1748
Fax Number	:	702-837-8292

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH M JARVIS
Credential	:	DPM
Telephone Number	:	702-810-1748

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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