Provider Demographics
NPI:1770999419
Name:ORLANDO FOOT AND ANKLE CLINIC, INC.
Entity type:Organization
Organization Name:ORLANDO FOOT AND ANKLE CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-423-1234
Mailing Address - Street 1:PO BOX 140233
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-0233
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:339 CYPRESS PKWY
Practice Address - Street 2:SUITE 240
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759
Practice Address - Country:US
Practice Address - Phone:407-279-5990
Practice Address - Fax:407-517-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029602300Medicaid