Provider Demographics
NPI:1124264833
Name:FOOT FITNESS CENTER PODIATRY GROUP
Entity type:Organization
Organization Name:FOOT FITNESS CENTER PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENIER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-777-2658
Mailing Address - Street 1:4976 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4158
Mailing Address - Country:US
Mailing Address - Phone:714-777-2658
Mailing Address - Fax:714-777-1055
Practice Address - Street 1:4976 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4158
Practice Address - Country:US
Practice Address - Phone:714-777-2658
Practice Address - Fax:714-777-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2097213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124264833OtherNPI
1588637193OtherNPI INDIVIDUAL
CAP00669656OtherRAILROAD MEDICARE
CA5568080001OtherDME
CABC719OtherPTAN
CABC718OtherPTAN - INDIVIDUAL
#E2097OtherMEDICARE ID-PROVIDER #
CAD03050OtherRAILROAD MEDICARE
CAP00669656OtherRAILROAD MEDICARE
CAD03050OtherRAILROAD MEDICARE
T11176Medicare UPIN