Provider Demographics
NPI:1033284591
Name:NORTH BAY FOOT AND ANKLE CLINIC, INC
Entity Type:Organization
Organization Name:NORTH BAY FOOT AND ANKLE CLINIC, INC
Other - Org Name:ADELINA B. STATEVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADELINA
Authorized Official - Middle Name:B
Authorized Official - Last Name:STATEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:707-546-2107
Mailing Address - Street 1:1041 4TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4329
Mailing Address - Country:US
Mailing Address - Phone:707-546-2107
Mailing Address - Fax:707-573-0315
Practice Address - Street 1:1041 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4329
Practice Address - Country:US
Practice Address - Phone:707-546-2107
Practice Address - Fax:707-573-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4562213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6451730001Medicare NSC
CACD176AMedicare PIN