Healthcare Provider Details

I. General information

NPI: 1093809097
Provider Name (Legal Business Name): CENTRAL FLORIDA FOOT AND ANKLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 6TH ST NW
WINTER HAVEN FL
33881-4630
US

IV. Provider business mailing address

PO BOX 7472
WINTER HAVEN FL
33883-7472
US

V. Phone/Fax

Practice location:
  • Phone: 863-299-4551
  • Fax: 863-299-2310
Mailing address:
  • Phone: 863-299-4551
  • Fax: 863-299-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2804
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3070
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2760
License Number StateFL

VIII. Authorized Official

Name: DR. TATIANA A WELLENS-BRUSCHAYT
Title or Position: PRESIDENT
Credential: D.P.M, PHD
Phone: 863-299-4551