=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710335476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT AND ANKLE EXCELLENCE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 GRANT AVE STE B
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19115-4370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-698-6133
-----------------------------------------------------
Fax | 215-698-6144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1927 GOODNAW ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19115-4720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-698-6133
-----------------------------------------------------
Fax | 215-698-6144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRUNI LEKA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 215-698-6133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | SC006479
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | SC006479
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------