MEDICARE: FOOTHEALS PODIATRY 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	213EP1101X	Primary Podiatric Medicine Podiatrist	E4125	CA

General Provider Information

NPI Number	:	1982032140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHEALS PODIATRY INC

Provider Business Mailing Address
First Line	:	1520 N MOUNTAIN AVE STE 122
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-1132
Country	:	US
Telephone Number	:	909-623-4484
Fax Number	:	909-623-4485

Provider Business Practice Location Address
First Line	:	1520 N MOUNTAIN AVE STE 122
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91762-1132
Country	:	US
Telephone Number	:	909-623-4484
Fax Number	:	909-623-4485

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL WACH
Credential	:	D.P.M.
Telephone Number	:	909-623-4484

Provider Enumeration Date	:	10/28/2013
Last Update Date	:	10/28/2013

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