Provider Demographics
NPI:1407417405
Name:PRO FOOT AND ANKLE CLINIC.INC
Entity Type:Organization
Organization Name:PRO FOOT AND ANKLE CLINIC.INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-502-6046
Mailing Address - Street 1:9896 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1643
Mailing Address - Country:US
Mailing Address - Phone:714-636-3032
Mailing Address - Fax:
Practice Address - Street 1:9896 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1643
Practice Address - Country:US
Practice Address - Phone:714-636-3032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE5409OtherPODIATRY