Healthcare Provider Details

I. General information

NPI: 1144453770
Provider Name (Legal Business Name): COMMUNITY FOOT CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2009
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31450 7 MILE RD
LIVONIA MI
48152-1374
US

IV. Provider business mailing address

2997 E HIGHLAND RD
HIGHLAND MI
48356-2811
US

V. Phone/Fax

Practice location:
  • Phone: 248-478-6363
  • Fax: 248-478-9779
Mailing address:
  • Phone: 248-887-3729
  • Fax: 248-889-8910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901000651
License Number StateMI

VIII. Authorized Official

Name: DR. GARY ALAN WASIAK
Title or Position: PRESIDENT
Credential: DPM
Phone: 248-478-6363