=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912645250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT ANKLE & LOWER LEG SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2022
-----------------------------------------------------
Last Update Date | 10/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 E SANTA CLARA ST
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 669-977-0200
-----------------------------------------------------
Fax | 669-333-3310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 E SANTA CLARA ST
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 669-977-0200
-----------------------------------------------------
Fax | 669-333-3310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YILMA KEBEDE KEBELO
-----------------------------------------------------
Credential | MD, DPM
-----------------------------------------------------
Telephone | 408-829-2904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------