Healthcare Provider Details

I. General information

NPI: 1477869204
Provider Name (Legal Business Name): JLA SENIOR FOOTCARE FLA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N PENINSULA DR STE A
DAYTONA BEACH FL
32118-4082
US

IV. Provider business mailing address

4870 S ASPEN CT
CANFIELD OH
44406-8469
US

V. Phone/Fax

Practice location:
  • Phone: 386-252-4678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO 3438
License Number StateFL

VIII. Authorized Official

Name: ANTHONY INNOCENZI
Title or Position: OWNER
Credential: DPM
Phone: 330-702-0978