Provider Demographics
NPI:1336818434
Name:ELLSWORTH FOOT AND ANKLE CLINIC
Entity type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-253-6886
Mailing Address - Street 1:9980 S 300 W STE 300
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:
Practice Address - Street 1:12523 S CREEK MEADOW RD STE 105
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7299
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLSWORTH FOOT AND ANKLE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty