Healthcare Provider Details

I. General information

NPI: 1689850638
Provider Name (Legal Business Name): ADVANCED FOOT AND ANKLE SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2008
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78-437 HWY 111
LA QUINTA CA
92253
US

IV. Provider business mailing address

42-335 WASHINGTON F-338
PALM DESERT CA
92211
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-3355
  • Fax: 760-771-5149
Mailing address:
  • Phone: 760-674-3355
  • Fax: 760-771-5149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE-3589
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3589
License Number StateCA

VIII. Authorized Official

Name: DR. DALE SHRUM
Title or Position: CEO
Credential: DPM
Phone: 760-674-3355