Healthcare Provider Details

I. General information

NPI: 1104683655
Provider Name (Legal Business Name): THOMAS LIM PODIATRY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

IV. Provider business mailing address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3668
  • Fax:
Mailing address:
  • Phone: 818-242-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA COLUCCI
Title or Position: MANAGER
Credential:
Phone: 818-242-3668