Basic Information
| Provider Information | |||||||||
| NPI: | 1659688380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JLA SENIOR FOOTCARE NM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4870 S ASPEN CT | ||||||||
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| City: | CANFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444068469 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 W AVE I | ||||||||
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| City: | LOVINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882605002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753965212 | ||||||||
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| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | INNOCENZI | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3307020978 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 331 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.