Provider Demographics
NPI:1598526204
Name:WELLNESS PODIATRY CORP
Entity Type:Organization
Organization Name:WELLNESS PODIATRY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-786-3434
Mailing Address - Street 1:685 TWELVE BRIDGES DR STE F
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-8689
Mailing Address - Country:US
Mailing Address - Phone:916-786-3434
Mailing Address - Fax:
Practice Address - Street 1:1650 LEAD HILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3072
Practice Address - Country:US
Practice Address - Phone:916-786-3434
Practice Address - Fax:916-786-6770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS PODIATRY CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty