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General NPI Number Information
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NPI Number | 1710302450
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Entity Type | Organization
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Legal Business Name | NEW AGE FOOT AND ANKLE PODIATRY PC
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Dates
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Enumeration Date | 03/04/2014
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Last Update Date | 03/04/2014
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Provider Practice Location Address
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Address Line | 705 IVY STREET
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City | GLENDALE
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State | CA
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Zip | 91204
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Country | US
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Telephone | 917-687-7528
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Fax |
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Provider Business Mailing Address
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Address Line | 20548 VENTURA BLVD APT 217
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City | WOODLAND HILLS
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State | CA
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Zip | 91364-6225
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Country | US
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Telephone | 917-687-7528
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALEKSANDER V LAVRENOV
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Credential | D.P.M.
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Telephone | 917-687-7528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | E 5019
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License Number State | CA
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