Healthcare Provider Details

I. General information

NPI: 1962977272
Provider Name (Legal Business Name): SLADE PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 E CHAPEL ST STE 101
SANTA MARIA CA
93454-4618
US

IV. Provider business mailing address

821 E CHAPEL ST STE 101
SANTA MARIA CA
93454-4618
US

V. Phone/Fax

Practice location:
  • Phone: 805-925-8703
  • Fax:
Mailing address:
  • Phone: 805-925-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRANDON JAMES SLADE
Title or Position: OWNER
Credential: DPM
Phone: 805-235-3887