Healthcare Provider Details

I. General information

NPI: 1487704417
Provider Name (Legal Business Name): FOOT AND ANKLE CENTER OF NEW JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 PARK AVE SUITE 3
PLAINFIELD NJ
07060-3026
US

IV. Provider business mailing address

1024 PARK AVE SUITE 3
PLAINFIELD NJ
07060-3026
US

V. Phone/Fax

Practice location:
  • Phone: 908-755-5545
  • Fax: 908-755-6065
Mailing address:
  • Phone: 908-755-5545
  • Fax: 908-755-6065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00274700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00274800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRISTEN MANNIX
Title or Position: OFFICE MANAGER
Credential:
Phone: 908-755-5545