Healthcare Provider Details

I. General information

NPI: 1063920338
Provider Name (Legal Business Name): KNOCK YOUR SOCKS OFF FOOT & ANKLE SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NW 168TH ST STE 303
NORTH MIAMI BEACH FL
33169-6051
US

IV. Provider business mailing address

19421 NE 18TH CT
NORTH MIAMI BEACH FL
33179-3655
US

V. Phone/Fax

Practice location:
  • Phone: 786-298-5861
  • Fax: 786-657-2758
Mailing address:
  • Phone: 510-914-1223
  • Fax: 786-657-2758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3966
License Number StateFL

VIII. Authorized Official

Name: MICHAEL NORRIS
Title or Position: CEO
Credential: DPM
Phone: 510-914-1223