Provider Demographics
NPI:1356557581
Name:INLAND PODIATRY CENTER PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:INLAND PODIATRY CENTER PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:LANDREY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-987-3211
Mailing Address - Street 1:9474 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5822
Mailing Address - Country:US
Mailing Address - Phone:909-987-3211
Mailing Address - Fax:909-987-0317
Practice Address - Street 1:9474 BASELINE RD
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-5822
Practice Address - Country:US
Practice Address - Phone:909-987-3211
Practice Address - Fax:909-987-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1457213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E14572Medicaid
CAE1457OtherLICENSE NUMBER
CA000E14572Medicaid
CAE1457OtherLICENSE NUMBER