=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376315465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FEET 1ST PODIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2023
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10807 LAUREL ST STE 220
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-527-3585
-----------------------------------------------------
Fax | 909-527-3627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10807 LAUREL ST STE 220
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-527-3585
-----------------------------------------------------
Fax | 909-527-3627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMMAD REZA AHMADINIA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-382-4939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0004X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------