Provider Demographics
NPI:1265203004
Name:REBOOT PODIATRY LLC
Entity type:Organization
Organization Name:REBOOT PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-655-3565
Mailing Address - Street 1:246B LIVINGSTON ST STE 133
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1902
Mailing Address - Country:US
Mailing Address - Phone:201-655-3565
Mailing Address - Fax:
Practice Address - Street 1:72 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2432
Practice Address - Country:US
Practice Address - Phone:201-655-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty