Healthcare Provider Details

I. General information

NPI: 1609129881
Provider Name (Legal Business Name): PINOLE PODIATRY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 APPIAN WAY STE 206
PINOLE CA
94564-2520
US

IV. Provider business mailing address

2150 APPIAN WAY STE 206
PINOLE CA
94564-2520
US

V. Phone/Fax

Practice location:
  • Phone: 510-724-1530
  • Fax:
Mailing address:
  • Phone: 510-724-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4413
License Number StateCA

VIII. Authorized Official

Name: MICHAEL D GRIMES
Title or Position: CEO
Credential: DPM
Phone: 510-724-1530