1124264833 NPI number — FOOT FITNESS CENTER PODIATRY GROUP

Table of content: (NPI 1124264833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124264833 NPI number — FOOT FITNESS CENTER PODIATRY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT FITNESS CENTER PODIATRY GROUP
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:
1124264833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4976 LAKEVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORBA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92886-4158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-777-2658
Provider Business Mailing Address Fax Number:
714-777-1055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4976 LAKEVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORBA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92886-4158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-777-2658
Provider Business Practice Location Address Fax Number:
714-777-1055
Provider Enumeration Date:
12/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRENIER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-777-2658

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E2097 , 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)

  • Identifier: 1124264833 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1588637193 . This is a "NPI INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00669656 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5568080001 . This is a "DME" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BC719 . This is a "PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BC718 . This is a "PTAN - INDIVIDUAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: #E2097 . This is a "MEDICARE ID-PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: D03050 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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