Provider Demographics
NPI:1770930919
Name:LAKE WALES FOOT AND ANKLE CARE, INC
Entity type:Organization
Organization Name:LAKE WALES FOOT AND ANKLE CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRERNA
Authorized Official - Middle Name:ALFA
Authorized Official - Last Name:MALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:863-676-1710
Mailing Address - Street 1:801 WOODLARK DR
Mailing Address - Street 2:HIGHLAND MEADOWS
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-7745
Mailing Address - Country:US
Mailing Address - Phone:863-676-1710
Mailing Address - Fax:
Practice Address - Street 1:408 S 1ST ST
Practice Address - Street 2:HIGHLAND MEADOWS
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4146
Practice Address - Country:US
Practice Address - Phone:863-676-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty