Provider Demographics
NPI:1154500221
Name:INDIAN WELLS PODIATRY GROUP
Entity Type:Organization
Organization Name:INDIAN WELLS PODIATRY GROUP
Other - Org Name:CALIFORNIA FOOT & ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-446-3338
Mailing Address - Street 1:1111 N CHINA LAKE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3131
Mailing Address - Country:US
Mailing Address - Phone:760-499-3270
Mailing Address - Fax:760-499-3275
Practice Address - Street 1:1111 N CHINA LAKE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-499-3270
Practice Address - Fax:760-499-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3355213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty