Provider Demographics
NPI:1457499725
Name:ALL SOUTH BAY FOOTCARE PODIATRY GROUP, INC.
Entity Type:Organization
Organization Name:ALL SOUTH BAY FOOTCARE PODIATRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:TELES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-326-0202
Mailing Address - Street 1:23365 HAWTHORNE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3720
Mailing Address - Country:US
Mailing Address - Phone:310-326-0202
Mailing Address - Fax:310-326-5826
Practice Address - Street 1:23365 HAWTHORNE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3720
Practice Address - Country:US
Practice Address - Phone:310-326-0202
Practice Address - Fax:310-326-5826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2898213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E28980Medicaid
CA000E28980Medicaid
CAT19247Medicare UPIN