Provider Demographics
NPI:1467550897
Name:PREMIUM PODIATRY, INC.
Entity Type:Organization
Organization Name:PREMIUM PODIATRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-782-0559
Mailing Address - Street 1:18701 SHERMAN WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4049
Mailing Address - Country:US
Mailing Address - Phone:818-782-0559
Mailing Address - Fax:818-782-8308
Practice Address - Street 1:18701 SHERMAN WAY STE 2
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4049
Practice Address - Country:US
Practice Address - Phone:818-782-0559
Practice Address - Fax:818-782-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1306213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10084Medicare UPIN
CA0866320001Medicare NSC