Healthcare Provider Details

I. General information

NPI: 1912696782
Provider Name (Legal Business Name): WELLNESS PODIATRY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3257 PROFESSIONAL DR STE E
AUBURN CA
95602-2460
US

IV. Provider business mailing address

685 TWELVE BRIDGES DR STE F
LINCOLN CA
95648-8689
US

V. Phone/Fax

Practice location:
  • Phone: 503-823-7171
  • Fax:
Mailing address:
  • Phone: 916-786-3434
  • Fax: 916-786-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN PHAM
Title or Position: OWNER
Credential: DPM
Phone: 510-551-3804