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General NPI Number Information
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NPI Number | 1841576998
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Entity Type | Organization
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Legal Business Name | GRAND LAKE FOOT & ANKLE INC
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Dates
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Enumeration Date | 11/02/2011
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Last Update Date | 03/22/2016
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Provider Practice Location Address
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Address Line | 1222 IRMSCHER BLVD
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City | CELINA
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State | OH
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Zip | 45822-8305
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Country | US
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Telephone | 419-586-7874
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Fax | 419-586-2776
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Provider Business Mailing Address
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Address Line | 1222 IRMSCHER BLVD
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City | CELINA
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State | OH
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Zip | 45822-8305
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Country | US
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Telephone | 419-586-7874
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Fax | 419-586-2776
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Authorized Official
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Title or Position | DPM
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Name | MARY BENJAMIN SWONGER
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Credential | DPM
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Telephone | 419-586-7874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 36002772
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License Number State | OH
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