Provider Demographics
NPI:1104323963
Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARAVARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-828-0011
Mailing Address - Street 1:2121 WILSHIRE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5742
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:310-828-0011
Practice Address - Street 1:10515 BALBOA BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6350
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY FOOT & ANKLE INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty