Healthcare Provider Details

I. General information

NPI: 1265128631
Provider Name (Legal Business Name): MELECA FOOT AND ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 PASEO REYES DR
ST AUGUSTINE FL
32095
US

IV. Provider business mailing address

432 PASEO REYES DR
ST AUGUSTINE FL
32095
US

V. Phone/Fax

Practice location:
  • Phone: 517-990-7844
  • Fax:
Mailing address:
  • Phone: 517-990-7844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: SALVATORE MELECA
Title or Position: AUTHORIZED OFFICIAL
Credential: DPM
Phone: 517-990-7844