Provider Demographics
NPI:1154747947
Name:TRI-CITY FOOT & ANKLE CENTER, LLC
Entity type:Organization
Organization Name:TRI-CITY FOOT & ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:THIELGES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:509-591-9454
Mailing Address - Street 1:9613 SANDIFUR PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8028
Mailing Address - Country:US
Mailing Address - Phone:509-591-9454
Mailing Address - Fax:509-578-1118
Practice Address - Street 1:9613 SANDIFUR PKWY STE B
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8028
Practice Address - Country:US
Practice Address - Phone:509-591-9454
Practice Address - Fax:509-578-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60436994213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2036331Medicaid
WA2036331Medicaid
WAG8927945Medicare PIN