Provider Demographics
NPI:1629259429
Name:GUARDIAN ANGEL FOOT CARE OF BRADENTON VENICE AND ENGLEWOOD INC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL FOOT CARE OF BRADENTON VENICE AND ENGLEWOOD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:941-473-3338
Mailing Address - Street 1:2400 S MCCALL RD STE F
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-5136
Mailing Address - Country:US
Mailing Address - Phone:941-473-3338
Mailing Address - Fax:
Practice Address - Street 1:2400 S MCCALL RD STE F
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-5136
Practice Address - Country:US
Practice Address - Phone:941-473-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI373Medicare PIN
SC5632150001Medicare NSC