Healthcare Provider Details

I. General information

NPI: 1306606579
Provider Name (Legal Business Name): CONVALESCENT PODIATRY CARE A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 DEL AMO BLVD STE 102
LAKEWOOD CA
90712-2761
US

IV. Provider business mailing address

5445 DEL AMO BLVD STE 102
LAKEWOOD CA
90712-2761
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-0811
  • Fax: 562-866-4046
Mailing address:
  • Phone: 562-867-0811
  • Fax: 562-866-4046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOOYOUNG HAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 657-200-5680