Provider Demographics
NPI:1477978955
Name:PRESTIGE FOOT & ANKLE CENTER LLC
Entity Type:Organization
Organization Name:PRESTIGE FOOT & ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-723-2111
Mailing Address - Street 1:784 MEDINA RD
Mailing Address - Street 2:107
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9634
Mailing Address - Country:US
Mailing Address - Phone:330-591-9635
Mailing Address - Fax:330-591-4150
Practice Address - Street 1:5655 HUDSON DR
Practice Address - Street 2:STE 315
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-4451
Practice Address - Country:US
Practice Address - Phone:330-591-9635
Practice Address - Fax:330-591-4150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003592332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies