Provider Demographics
NPI:1235313123
Name:FOOT AND ANKLE WELLNESS CLINIC
Entity Type:Organization
Organization Name:FOOT AND ANKLE WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MANCHERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-937-6903
Mailing Address - Street 1:6310 SAN VICENTE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5458
Mailing Address - Country:US
Mailing Address - Phone:323-937-6903
Mailing Address - Fax:323-210-7171
Practice Address - Street 1:6310 SAN VICENTE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5458
Practice Address - Country:US
Practice Address - Phone:323-937-6903
Practice Address - Fax:323-210-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4429213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E28430Medicaid