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General NPI Number Information
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NPI Number | 1972875854
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Entity Type | Organization
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Legal Business Name | ADVANCED FOOT & ANKLE CENTER LLC
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Dates
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Enumeration Date | 02/07/2012
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Last Update Date | 09/12/2019
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Provider Practice Location Address
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Address Line | 111 BOYD CIR
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-7016
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Country | US
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Telephone | 219-405-3775
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Fax | 219-405-3775
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Provider Business Mailing Address
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Address Line | 27 ASPEN RD
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City | PORTAGE
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State | IN
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Zip | 46368-1027
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Country | US
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Telephone | 219-405-3775
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Fax | 219-405-3775
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Authorized Official
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Title or Position | DOCTOR
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Name | CYNTHIA GRUNDY
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Credential | DPM
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Telephone | 219-405-3775
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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 | 07000941A
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License Number State | IN
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