=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124264833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT FITNESS CENTER PODIATRY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2008
-----------------------------------------------------
Last Update Date | 05/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4976 LAKEVIEW AVE
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-777-2658
-----------------------------------------------------
Fax | 714-777-1055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4976 LAKEVIEW AVE
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-777-2658
-----------------------------------------------------
Fax | 714-777-1055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHARD GRENIER
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 714-777-2658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E2097
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------