Provider Demographics
NPI:1861825523
Name:FALLBROOK PODIATRY, INC
Entity Type:Organization
Organization Name:FALLBROOK PODIATRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRIGORIY
Authorized Official - Middle Name:N
Authorized Official - Last Name:PATISH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-728-4800
Mailing Address - Street 1:407 POTTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3086
Mailing Address - Country:US
Mailing Address - Phone:760-728-4800
Mailing Address - Fax:760-728-0061
Practice Address - Street 1:407 POTTER ST STE A
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3086
Practice Address - Country:US
Practice Address - Phone:760-728-4800
Practice Address - Fax:760-728-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4987213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty