=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174913065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC FOOT SPECALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2015
-----------------------------------------------------
Last Update Date | 01/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9319 PINECROFT DR #120
-----------------------------------------------------
City | THE WOODLANDS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77380-3484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-862-3338
-----------------------------------------------------
Fax | 713-862-8328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 W 27TH ST #110
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77008-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-862-3338
-----------------------------------------------------
Fax | 713-862-8328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY L HAASE
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 713-862-3338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 1746
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------