=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154516185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELAND FOOT AND LEG CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 03/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 844 N STONE ST STE 208
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-3733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 844 N STONE ST STE 208
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-738-3733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ MANAGER
-----------------------------------------------------
Name | DR. JENNEFFER SCHNELLER PULAPAKA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 386-738-3733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3160
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------