Healthcare Provider Details

I. General information

NPI: 1124201991
Provider Name (Legal Business Name): FOOT, ANKLE & LEG SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17842 NW 2ND STREET
PEMBROKE PINES FL
33029
US

IV. Provider business mailing address

3607 OLD CONEJO RD
THOUSAND OAKS CA
91320-2123
US

V. Phone/Fax

Practice location:
  • Phone: 954-389-5900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberPO02570
License Number StateFL

VIII. Authorized Official

Name: AUGUSTINE BOLLO
Title or Position: PHYSICIAN
Credential:
Phone: 954-389-5900