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General NPI Number Information
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NPI Number | 1639399371
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Entity Type | Organization
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Legal Business Name | CORONADO FOOT SPECIALISTS PODIATRY CLINIC INC
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 05/12/2014
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Provider Practice Location Address
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Address Line | 1121 10TH ST
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City | CORONADO
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State | CA
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Zip | 92118-3401
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Country | US
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Telephone | 619-435-0151
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Fax | 619-435-9316
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Provider Business Mailing Address
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Address Line | 1121 10TH ST
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City | CORONADO
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State | CA
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Zip | 92118-3401
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Country | US
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Telephone | 619-435-0151
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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. BRUCE ALAN MANCHEL
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Credential | DPM
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Telephone | 619-435-0151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | E2930
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License Number State | CA
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