Healthcare Provider Details

I. General information

NPI: 1679714166
Provider Name (Legal Business Name): ACCESS WOUND CARE AND PODIATRY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE SUITE 120
GLENDALE CA
91204-2500
US

IV. Provider business mailing address

1510 S. CENTRAL AVE SUITE 120
GLENDALE CA
91204
US

V. Phone/Fax

Practice location:
  • Phone: 800-480-3338
  • Fax: 818-790-3121
Mailing address:
  • Phone: 800-480-3338
  • Fax: 818-790-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3817
License Number StateCA

VIII. Authorized Official

Name: CHARLES BLAINE
Title or Position: DPM
Credential: DPM
Phone: 800-480-3338