Provider Demographics
NPI:1942317284
Name:L&D PROFESSIONAL, INC.
Entity Type:Organization
Organization Name:L&D PROFESSIONAL, INC.
Other - Org Name:FONTANA FAMILY FOOT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VOUCH
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LUN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-350-3032
Mailing Address - Street 1:8110 MANGO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3603
Mailing Address - Country:US
Mailing Address - Phone:909-350-3032
Mailing Address - Fax:909-350-0294
Practice Address - Street 1:8110 MANGO AVE STE 102
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3603
Practice Address - Country:US
Practice Address - Phone:909-350-3032
Practice Address - Fax:909-350-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4444213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU95014Medicare UPIN
CAV08737Medicare UPIN
CA000E44441Medicare PIN
CA000E4441Medicare ID - Type UnspecifiedPPIN
CA5503210001Medicare NSC
CA000E4660Medicare ID - Type UnspecifiedMEDICARE NUMBER
CAZZZ02254ZMedicare ID - Type UnspecifiedGROUP ID