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General NPI Number Information
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NPI Number | 1407025182
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Entity Type | Organization
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Legal Business Name | ADVANCE FOOT WORKS LLC
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Dates
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Enumeration Date | 02/26/2008
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Last Update Date | 02/26/2008
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Provider Practice Location Address
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Address Line | 408 E UPLAND RD
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City | ITHACA
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State | NY
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Zip | 14850-2527
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Country | US
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Telephone | 917-903-7116
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Fax |
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Provider Business Mailing Address
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Address Line | 408 E UPLAND RD
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City | ITHACA
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State | NY
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Zip | 14850-2527
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Country | US
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Telephone | 917-903-7116
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Fax |
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. VICTOR VILLAGONZALO
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Credential | DPM
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Telephone | 917-903-7116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | N05881
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License Number State | NY
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