Provider Demographics
NPI:1538338884
Name:CC FOOT CLINIC PC
Entity type:Organization
Organization Name:CC FOOT CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LORRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:303-355-1695
Mailing Address - Street 1:2121 S ONEIDA ST
Mailing Address - Street 2:STE 270
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-2549
Mailing Address - Country:US
Mailing Address - Phone:303-355-1695
Mailing Address - Fax:303-355-1834
Practice Address - Street 1:2121 S ONEIDA ST
Practice Address - Street 2:STE 270
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-2549
Practice Address - Country:US
Practice Address - Phone:303-355-1695
Practice Address - Fax:303-355-1834
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CC FOOT CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-20
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO308213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01003086Medicaid
0349500001Medicare NSC
CO319178Medicare PIN
COCOB4161Medicare PIN
CO01003086Medicaid