Healthcare Provider Details

I. General information

NPI: 1326569708
Provider Name (Legal Business Name): SEASIDE FOOT AND ANKLE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15706 POMERADO RD STE S-102
POWAY CA
92064
US

IV. Provider business mailing address

15706 POMERADO RD STE S-102
POWAY CA
92064-2067
US

V. Phone/Fax

Practice location:
  • Phone: 858-485-1494
  • Fax:
Mailing address:
  • Phone: 760-390-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5268
License Number StateCA

VIII. Authorized Official

Name: DR. COLLIN SMITH
Title or Position: PRESIDENT
Credential: DPM
Phone: 760-390-2942