Provider Demographics
NPI:1871624908
Name:ADULT & CHILDRENS FOOTCARE SPECIALISTS PC
Entity type:Organization
Organization Name:ADULT & CHILDRENS FOOTCARE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-836-4868
Mailing Address - Street 1:PO BOX 12815
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0687
Mailing Address - Country:US
Mailing Address - Phone:520-836-4868
Mailing Address - Fax:520-836-0759
Practice Address - Street 1:1760 E FLORENCE BLVD STE 160
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-4767
Practice Address - Country:US
Practice Address - Phone:520-836-4868
Practice Address - Fax:520-836-0759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480027517OtherRAILROAD MEDICARE
AZ189705000OtherDEPARTMENT OF LABOR
AZ357774Medicaid
AZ4129380001Medicare NSC
AZ189705000OtherDEPARTMENT OF LABOR
AZZDPM447Medicare PIN