Healthcare Provider Details

I. General information

NPI: 1063459675
Provider Name (Legal Business Name): SON SHINE FOOT AND ANKLE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SE GOLDTREE DR SUITE B
PORT ST LUCIE FL
34952-7563
US

IV. Provider business mailing address

PO BOX 8210
PORT ST LUCIE FL
34985-8210
US

V. Phone/Fax

Practice location:
  • Phone: 772-380-0900
  • Fax: 772-380-0901
Mailing address:
  • Phone: 772-380-0900
  • Fax: 772-380-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2649
License Number StateFL

VIII. Authorized Official

Name: DR. ALBERT ANDREW DERRICO
Title or Position: PHYSICIAN
Credential: DPM
Phone: 772-380-0900