Healthcare Provider Details

I. General information

NPI: 1841576998
Provider Name (Legal Business Name): GRAND LAKE FOOT & ANKLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 IRMSCHER BLVD
CELINA OH
45822-8305
US

IV. Provider business mailing address

1222 IRMSCHER BLVD
CELINA OH
45822-8305
US

V. Phone/Fax

Practice location:
  • Phone: 419-586-7874
  • Fax: 419-586-2776
Mailing address:
  • Phone: 419-586-7874
  • Fax: 419-586-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36002772
License Number StateOH

VIII. Authorized Official

Name: MARY BENJAMIN SWONGER
Title or Position: DPM
Credential: DPM
Phone: 419-586-7874