MEDICARE: WEST COAST FOOT AND ANKLE INSTITUTE PC

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	E5019	CA

General Provider Information

NPI Number	:	1932506516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST COAST FOOT AND ANKLE INSTITUTE PC

Provider Business Mailing Address
First Line	:	20548 VENTURA BLVD APT 217
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6470
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20548 VENTURA BLVD APT 217
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91364-6470
Country	:	US
Telephone Number	:	917-687-7528
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEKSANDER VALENTINOVICH LAVRENOV
Credential	:	D.P.M.
Telephone Number	:	917-687-7528

Provider Enumeration Date	:	11/26/2014
Last Update Date	:	11/26/2014

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