MEDICARE: KINETIC FOOT AND ANKLE, LLC

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	25MD00323600	NJ

General Provider Information

NPI Number	:	1932686334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINETIC FOOT AND ANKLE, LLC

Provider Business Mailing Address
First Line	:	50 LINCOLN AVE
Second Line	:
City	:	LITTLE FALLS
State	:	NJ
Zip	:	07424-1535
Country	:	US
Telephone Number	:	862-520-8895
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 MCBRIDE AVE UNIT 103
Second Line	:
City	:	WOODLAND PARK
State	:	NJ
Zip	:	07424-2535
Country	:	US
Telephone Number	:	862-520-8895
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RICO MIGUEL ALMAZAN VISPERAS
Credential	:	D.P.M.
Telephone Number	:	862-520-8895

Provider Enumeration Date	:	07/27/2018
Last Update Date	:	12/17/2018

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