1710645007 NPI number — CERTIFIED FOOT & ANKLE SPECIALISTS

Table of content: (NPI 1710645007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710645007 NPI number — CERTIFIED FOOT & ANKLE SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CERTIFIED FOOT & ANKLE SPECIALISTS
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:
6
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:
1710645007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746232
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
754-702-3359
Provider Business Mailing Address Fax Number:
561-288-9045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N COMMERCE PKWY STE 321
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33326-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-349-7796
Provider Business Practice Location Address Fax Number:
954-217-3538
Provider Enumeration Date:
12/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KINMON
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-995-0229

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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