=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407952328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 101ST AVENUE FOOT CARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2006
-----------------------------------------------------
Last Update Date | 08/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10214 101ST AVE
-----------------------------------------------------
City | OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-641-2100
-----------------------------------------------------
Fax | 718-641-2101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10214 101ST AVE
-----------------------------------------------------
City | OZONE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11416-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-641-2100
-----------------------------------------------------
Fax | 718-641-2101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH MICALLEF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-641-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------