Provider Demographics
NPI:1710220207
Name:PREMIER FOOT AND ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:PREMIER FOOT AND ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-935-0503
Mailing Address - Street 1:18525 WEST DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160
Mailing Address - Country:US
Mailing Address - Phone:305-935-0503
Mailing Address - Fax:305-359-9601
Practice Address - Street 1:18525 WEST DIXIE HWY
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160
Practice Address - Country:US
Practice Address - Phone:305-935-0503
Practice Address - Fax:305-359-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3487213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHF317AMedicare PIN