Basic Information
Provider Information | |||||||||
NPI: | 1700051497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHELAN-OKANOGAN FOOT & ANKLE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 503 E HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | CHELAN | ||||||||
State: | WA | ||||||||
PostalCode: | 988168631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096823300 | ||||||||
FaxNumber: | 5096826131 | ||||||||
Practice Location | |||||||||
Address1: | 503 E HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | CHELAN | ||||||||
State: | WA | ||||||||
PostalCode: | 988168631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096823300 | ||||||||
FaxNumber: | 5096826131 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2008 | ||||||||
LastUpdateDate: | 04/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HORLEBEIN | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5096820232 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | P0694 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 7104128 | 05 | WA |   | MEDICAID | 4844668 | 01 | WA | DME | OTHER | 4266020001 | 01 |   | DMERC | OTHER | 0146103 | 01 | WA | L&I | OTHER |