Provider Demographics
NPI:1700665775
Name:FOOT DOCTOR LLC
Entity type:Organization
Organization Name:FOOT DOCTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:307-359-9566
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0804
Mailing Address - Country:US
Mailing Address - Phone:307-359-9566
Mailing Address - Fax:
Practice Address - Street 1:808 FREMONT ST
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420-1210
Practice Address - Country:US
Practice Address - Phone:307-359-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Multi-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility