Provider Demographics
NPI:1932686334
Name:KINETIC FOOT AND ANKLE, LLC
Entity Type:Organization
Organization Name:KINETIC FOOT AND ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICO MIGUEL
Authorized Official - Middle Name:ALMAZAN
Authorized Official - Last Name:VISPERAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:862-520-8895
Mailing Address - Street 1:50 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-1535
Mailing Address - Country:US
Mailing Address - Phone:862-520-8895
Mailing Address - Fax:
Practice Address - Street 1:1030 MCBRIDE AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2535
Practice Address - Country:US
Practice Address - Phone:862-520-8895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00323600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty