Provider Demographics
NPI:1568649945
Name:MICHAEL L WACH, DPM, PODIATRY CORP
Entity Type:Organization
Organization Name:MICHAEL L WACH, DPM, PODIATRY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-623-4484
Mailing Address - Street 1:1520 N MOUNTAIN AVE
Mailing Address - Street 2:BLDG. E 122
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1128
Mailing Address - Country:US
Mailing Address - Phone:909-623-4484
Mailing Address - Fax:909-623-4485
Practice Address - Street 1:1520 N MOUNTAIN AVE
Practice Address - Street 2:BLDG. E 122
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1128
Practice Address - Country:US
Practice Address - Phone:909-623-4484
Practice Address - Fax:909-623-4485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4125213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6066440001Medicare NSC