Provider Demographics
NPI:1508887704
Name:AMBULATORY ANKLE & FOOT CENTER OF FLORIDA INC
Entity Type:Organization
Organization Name:AMBULATORY ANKLE & FOOT CENTER OF FLORIDA INC
Other - Org Name:AMBULATORY ANKLE & FOOT CENTER OF FL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-423-1234
Mailing Address - Street 1:3670 MAGUIRE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3071
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:1509 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2116
Practice Address - Country:US
Practice Address - Phone:407-836-6155
Practice Address - Fax:407-839-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL740261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079077000Medicaid
FLF1140Medicare PIN