Provider Demographics
NPI:1154398527
Name:SMOKY VALLEY FOOT CENTER PA
Entity type:Organization
Organization Name:SMOKY VALLEY FOOT CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:785-263-0555
Mailing Address - Street 1:515 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:KS
Mailing Address - Zip Code:67410-2153
Mailing Address - Country:US
Mailing Address - Phone:785-263-0555
Mailing Address - Fax:
Practice Address - Street 1:515 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:KS
Practice Address - Zip Code:67410-2153
Practice Address - Country:US
Practice Address - Phone:785-263-6670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5962580001Medicare NSC
KS144201Medicare PIN