Provider Demographics
NPI:1053399964
Name:COLONIAL FOOT & ANKLE CENTER LLC
Entity type:Organization
Organization Name:COLONIAL FOOT & ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-653-2656
Mailing Address - Street 1:121 N EWING ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3364
Mailing Address - Country:US
Mailing Address - Phone:740-653-2656
Mailing Address - Fax:740-687-0300
Practice Address - Street 1:121 N EWING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3364
Practice Address - Country:US
Practice Address - Phone:740-653-2656
Practice Address - Fax:740-687-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2587204Medicaid
OHDE6505OtherRAILROAD MEDICARE
OH2587204Medicaid
OH5546630001Medicare NSC