Healthcare Provider Details

I. General information

NPI: 1265470678
Provider Name (Legal Business Name): BROADWAY FOOT & ANKLE PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 W CREST VIEW LOOP SE
SNOQUALMIE WA
98065-8912
US

IV. Provider business mailing address

PO BOX 24963
SEATTLE WA
98124-0963
US

V. Phone/Fax

Practice location:
  • Phone: 425-396-5424
  • Fax:
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-320-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. BARRY L LICHTER
Title or Position: SOLE PROPRIETOR
Credential: DPM
Phone: 206-386-2800