Healthcare Provider Details

I. General information

NPI: 1902208044
Provider Name (Legal Business Name): HIGH PERFORMANCE FOOT AND ANKLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 ATLANTIC AVE BLDG C, STE 3
MANASQUAN NJ
08736-1005
US

IV. Provider business mailing address

1903 ATLANTIC AVE BLDG C, STE 3
MANASQUAN NJ
08736-1005
US

V. Phone/Fax

Practice location:
  • Phone: 732-528-2218
  • Fax: 732-528-2234
Mailing address:
  • Phone: 732-528-2218
  • Fax: 732-528-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00269900
License Number StateNJ

VIII. Authorized Official

Name: DR. STACEY ALANA PAUKOVITZ
Title or Position: OWNER/PHYSICIAN
Credential: DPM
Phone: 732-330-0924