Provider Demographics
NPI:1326182866
Name:BRENTWOOD FOOT AND ANKLE CLINIC, INC.
Entity Type:Organization
Organization Name:BRENTWOOD FOOT AND ANKLE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:925-634-1009
Mailing Address - Street 1:71 SAND CREEK RD STE L
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-7319
Mailing Address - Country:US
Mailing Address - Phone:925-634-1009
Mailing Address - Fax:925-634-8262
Practice Address - Street 1:71 SAND CREEK RD STE L
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-7319
Practice Address - Country:US
Practice Address - Phone:925-634-1009
Practice Address - Fax:925-634-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4095261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194440001Medicare NSC