MEDICARE: LAKE WALES FOOT AND ANKLE CARE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770930919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WALES FOOT AND ANKLE CARE, INC

Provider Business Mailing Address
First Line	:	801 WOODLARK DR
Second Line	:	HIGHLAND MEADOWS
City	:	HAINES CITY
State	:	FL
Zip	:	33844-7745
Country	:	US
Telephone Number	:	863-676-1710
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 S 1ST ST
Second Line	:	HIGHLAND MEADOWS
City	:	LAKE WALES
State	:	FL
Zip	:	33853-4146
Country	:	US
Telephone Number	:	863-676-1710
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PRERNA ALFA MALL
Credential	:	DPM
Telephone Number	:	863-676-1710

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	09/26/2016

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