Provider Demographics
NPI:1639399371
Name:CORONADO FOOT SPECIALISTS PODIATRY CLINIC INC
Entity Type:Organization
Organization Name:CORONADO FOOT SPECIALISTS PODIATRY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MANCHEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:619-435-0151
Mailing Address - Street 1:1121 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3401
Mailing Address - Country:US
Mailing Address - Phone:619-435-0151
Mailing Address - Fax:
Practice Address - Street 1:1121 10TH ST
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3401
Practice Address - Country:US
Practice Address - Phone:619-435-0151
Practice Address - Fax:619-435-9316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2930213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE10040Medicare PIN
CA0432910001Medicare NSC
CAW15915Medicare UPIN