Healthcare Provider Details

I. General information

NPI: 1700535705
Provider Name (Legal Business Name): RIVERSIDE FOOT AND ANKLE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 BROCKTON AVE STE 211
RIVERSIDE CA
92506-2223
US

IV. Provider business mailing address

3521 LOMITA BLVD STE 103
TORRANCE CA
90505-5041
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-6643
  • Fax: 909-946-6130
Mailing address:
  • Phone: 310-534-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LISA BRESHEARS
Title or Position: COO
Credential: DPM
Phone: 310-534-9131