Organization Name: | JLA SENIOR FOOTCARE NM LLC |
NPI Number: | 1659688380 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | ANTHONY INNOCENZI (OWNER) |
Mailing Address: | 1600 W Ave I Lovington |
State: | NM US |
Postal Code: | 882605002 |
Phone Number: | 5753965212 |
Fax Number: | |
NPI Enumeration Date: | 09/01/2010 |
NPI Last Update Date: | 09/01/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 213ES0131X |
License Number: | 331 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NM |
Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
Taxonomy Classification: | Podiatrist |
Taxonomy Specialization: | Foot Surgery |
Taxonomy Definition: |