Healthcare Provider Details

I. General information

NPI: 1124264833
Provider Name (Legal Business Name): FOOT FITNESS CENTER PODIATRY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4976 LAKEVIEW AVE
YORBA LINDA CA
92886-4158
US

IV. Provider business mailing address

4976 LAKEVIEW AVE
YORBA LINDA CA
92886-4158
US

V. Phone/Fax

Practice location:
  • Phone: 714-777-2658
  • Fax: 714-777-1055
Mailing address:
  • Phone: 714-777-2658
  • Fax: 714-777-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE2097
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD GRENIER
Title or Position: OWNER
Credential: DPM
Phone: 714-777-2658