Healthcare Provider Details

I. General information

NPI: 1730901216
Provider Name (Legal Business Name): HARLIS FAMILY FOOT AND ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NW PRIMA VISTA BLVD STE 209
PORT SAINT LUCIE FL
34983-8731
US

IV. Provider business mailing address

475 NW PRIMA VISTA BLVD STE 209
PORT SAINT LUCIE FL
34983-8731
US

V. Phone/Fax

Practice location:
  • Phone: 772-210-3339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTYN BILLINGS
Title or Position: CREDENTIALING
Credential:
Phone: 412-655-4362