Healthcare Provider Details

I. General information

NPI: 1508056326
Provider Name (Legal Business Name): LIGHTHOUSE FOOT & ANKLE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NE 36TH ST SUITE 203
LIGHTHOUSE PT FL
33064-7574
US

IV. Provider business mailing address

PO BOX 50163
LIGHTHOUSE PT FL
33074-0163
US

V. Phone/Fax

Practice location:
  • Phone: 954-933-9033
  • Fax: 954-934-0060
Mailing address:
  • Phone: 954-933-9033
  • Fax: 954-934-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3030
License Number StateFL

VIII. Authorized Official

Name: DR. COLETTE TARA D'ALTILIO
Title or Position: MANAGEING MEMBER
Credential: D.P.M.
Phone: 954-933-9033