Provider Demographics
NPI:1063607950
Name:PODIATRY ASSOCIATES OF THE PALM BEACHES LLC
Entity type:Organization
Organization Name:PODIATRY ASSOCIATES OF THE PALM BEACHES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALI
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:ETHEREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:786-271-7688
Mailing Address - Street 1:1616 39TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3634
Mailing Address - Country:US
Mailing Address - Phone:786-271-7688
Mailing Address - Fax:561-848-1940
Practice Address - Street 1:8190 OKEECHOBEE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-2047
Practice Address - Country:US
Practice Address - Phone:561-358-6054
Practice Address - Fax:561-848-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty