Healthcare Provider Details

I. General information

NPI: 1992801658
Provider Name (Legal Business Name): THE FOOT AND ANKLE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 12/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15644 MADISON AVE 213
LAKEWOOD OH
44107-5622
US

IV. Provider business mailing address

PO BOX 80690
CANTON OH
44708-0690
US

V. Phone/Fax

Practice location:
  • Phone: 216-227-2194
  • Fax: 216-227-2196
Mailing address:
  • Phone: 330-833-5692
  • Fax: 330-833-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTINA M KOVACH
Title or Position: OWNER
Credential: DPM
Phone: 216-227-2194