1568649945 NPI number — MICHAEL L WACH, DPM, PODIATRY CORP

Table of content: (NPI 1568649945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568649945 NPI number — MICHAEL L WACH, DPM, PODIATRY CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL L WACH, DPM, PODIATRY 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:
1568649945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 N MOUNTAIN AVE
Provider Second Line Business Mailing Address:
BLDG. E 122
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91762-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-623-4484
Provider Business Mailing Address Fax Number:
909-623-4485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 N MOUNTAIN AVE
Provider Second Line Business Practice Location Address:
BLDG. E 122
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91762-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-623-4484
Provider Business Practice Location Address Fax Number:
909-623-4485
Provider Enumeration Date:
01/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WACH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-623-4484

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  E4125 , 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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