MEDICARE: SOUTHERN CALIFORNIA PODIATRY GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1699862755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CALIFORNIA PODIATRY GROUP, INC.

Provider Business Mailing Address
First Line	:	6030 VALENCIA ST
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92880-3088
Country	:	US
Telephone Number	:	562-896-5899
Fax Number	:	562-236-1283

Provider Business Practice Location Address
First Line	:	2661 E FLORENCE AVE
Second Line	:	SUITE B
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-583-4440
Fax Number	:	323-583-4499

Authorized Official
Title or Position	:	TREASURER/SECRETARY
Name	:	MR. JASON WACH
Credential	:
Telephone Number	:	562-896-5899

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	08/22/2020

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