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General NPI Number Information
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NPI Number | 1023329331
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Entity Type | Organization
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Legal Business Name | PEACE RIVER ANKLE & FOOT, PL
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Dates
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Enumeration Date | 07/01/2010
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Last Update Date | 03/03/2011
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Provider Practice Location Address
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Address Line | 3440 CONWAY BLVD 1D
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-7000
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Country | US
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Telephone | 941-624-3668
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Fax |
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Provider Business Mailing Address
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Address Line | 3440 CONWAY BLVD 1D
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-7000
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Country | US
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Telephone | 941-624-3668
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Fax |
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Authorized Official
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Title or Position | OWNER/PODIATRIST
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Name | DR. HOLLY K WADDELL
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Credential | DPM
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Telephone | 941-624-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | PO3264
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License Number State | FL
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