=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497644009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT RESTORE PODIATRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2025
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11769 MOUNT GUNNISON CT
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91737-7918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-702-3422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11769 MOUNT GUNNISON CT
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91737-7918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-702-3422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST, CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. BRYAN KATZ
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 909-702-3422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------