=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275726291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANKLE AND FOOT CLINIC OF LAKEWOOD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2007
-----------------------------------------------------
Last Update Date | 06/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5225 CIRQUE DR W STE 100
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98467-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-474-4353
-----------------------------------------------------
Fax | 253-474-5850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5225 CIRQUE DR W STE 100
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98467-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-474-4353
-----------------------------------------------------
Fax | 253-474-5850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. CYNTHIA ANN FENBERG
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 253-474-4353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO00000302
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------