Provider Demographics
NPI:1871727677
Name:NORTH VALLEY PODIATRY, LLC
Entity type:Organization
Organization Name:NORTH VALLEY PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-216-6680
Mailing Address - Street 1:19636 N 27TH AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4013
Mailing Address - Country:US
Mailing Address - Phone:602-943-7115
Mailing Address - Fax:602-943-7113
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:602-943-7115
Practice Address - Fax:602-943-7113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ630213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ124216Medicare PIN