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MOUNTAIN CREST FOOT AND ANKLE P.A.

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Company Details

Name: MOUNTAIN CREST FOOT AND ANKLE P.A.
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Active-Good Standing
Date of registration: 26 Aug 2002 (23 years ago)
Financial Date End: 31 Aug 2026
Entity Number: 442288
Place of Formation: IDAHO
File Number: 442288
ZIP code: 83404
County: Bonneville County
Mailing Address: 1628 ELK CREEK DR IDAHO FALLS, ID 83404-8349

Agent

Name Role Address
DR TIMOTHY BLACK Agent 1628 ELK CREEK DRIVE, IDAHO FALLS, ID 83404

President

Name Role Address Appointed On
TIMOTHY R BLACK President 1628 ELK CREEK DR, IDAHO FALLS, ID 83404 2020-07-07

National Provider Identifier

NPI Number:
1932191996

Authorized Person:

Name:
DR. TIMOTHY ROGER BLACK
Role:
OWNER/PHYSICIAN
Phone:

Taxonomy:

Selected Taxonomy:
213E00000X - Podiatrist
Is Primary:
Yes

Contacts:

Fax:
2085282802

Filing

Filing Name Filing Number Filing date
Annual Report 0006339779 2025-07-03
Annual Report 0005812189 2024-07-08
Annual Report 0005307065 2023-07-06
Annual Report 0004803066 2022-07-05
Annual Report 0004360614 2021-07-29

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Date of last update: 08 Aug 2025

Sources: Idaho Secretary of State