Provider Demographics
NPI:1760998736
Name:INNOVATIVE FOOT AND ANKLE CARE, PC
Entity Type:Organization
Organization Name:INNOVATIVE FOOT AND ANKLE CARE, PC
Other - Org Name:INNOVATIVE FOOT AND ANKLE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-500-3007
Mailing Address - Street 1:8283 GROVE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3139
Mailing Address - Country:US
Mailing Address - Phone:909-500-3007
Mailing Address - Fax:909-530-3007
Practice Address - Street 1:8283 GROVE AVE STE 106
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3139
Practice Address - Country:US
Practice Address - Phone:909-500-3007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-28
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Multi-Specialty