Healthcare Provider Details

I. General information

NPI: 1538180674
Provider Name (Legal Business Name): ASSOCIATED FOOT AND ANKLE SPECIALISTS OF OHIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SHROYER RD
DAYTON OH
45419-3635
US

IV. Provider business mailing address

6200 PLEASANT AVE SUITE 3
FAIRFIELD OH
45014-4670
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8448
  • Fax: 937-617-4840
Mailing address:
  • Phone: 937-435-6585
  • Fax: 937-435-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003238
License Number StateOH

VIII. Authorized Official

Name: DR. LISA NICELY
Title or Position: PRESIDENT/OWNER
Credential: D.P.M.
Phone: 937-293-8448