Healthcare Provider Details

I. General information

NPI: 1427350511
Provider Name (Legal Business Name): FOOT AND ANKLE SPORT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17751 SW 2ND ST
PEMBROKE PINES FL
33029-3924
US

IV. Provider business mailing address

17751 SW 2ND ST
PEMBROKE PINES FL
33029-3924
US

V. Phone/Fax

Practice location:
  • Phone: 954-450-0099
  • Fax: 866-381-9207
Mailing address:
  • Phone: 954-450-0099
  • Fax: 866-381-9207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2570
License Number StateFL

VIII. Authorized Official

Name: AUGUSTINE A. BOLLO
Title or Position: OWNER
Credential: DPM
Phone: 954-450-0099