1275867228 NPI number — BROCKTON PODIATRY GROUP A PROF CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275867228 NPI number — BROCKTON PODIATRY GROUP A PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROCKTON PODIATRY GROUP A PROF CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275867228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 E FERN AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92373-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-793-2379
Provider Business Mailing Address Fax Number:
909-793-9660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 E FERN AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
REDLANDS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92373-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-793-2379
Provider Business Practice Location Address Fax Number:
909-793-9660
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DURRANT
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
909-793-2379

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E1514 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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