Provider Demographics
NPI:1679218598
Name:CHARLOTTE LIMB PRESERVATION & DIABETIC FOOT CENTER
Entity Type:Organization
Organization Name:CHARLOTTE LIMB PRESERVATION & DIABETIC FOOT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENBOGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-841-3619
Mailing Address - Street 1:10035 PARK CEDAR DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8910
Mailing Address - Country:US
Mailing Address - Phone:917-841-3619
Mailing Address - Fax:
Practice Address - Street 1:10035 PARK CEDAR DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8910
Practice Address - Country:US
Practice Address - Phone:917-841-3619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty