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General NPI Number Information
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NPI Number | 1346731742
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Entity Type | Organization
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Legal Business Name | ADVANCED AGILITY FOOT & ANKLE, LLC
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Dates
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Enumeration Date | 05/22/2018
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Last Update Date | 05/22/2018
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Provider Practice Location Address
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Address Line | 1151 MIRANDA LN
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City | KISSIMMEE
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State | FL
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Zip | 34741-0763
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Country | US
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Telephone | 405-227-8453
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Fax | 407-483-4139
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Provider Business Mailing Address
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Address Line | 3001 LANGDON LN N
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City | KISSIMMEE
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State | FL
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Zip | 34741-7714
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW MARTINCEVIC
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Credential | DPM
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Telephone | 405-227-8453
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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 | PO3871
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License Number State | FL
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