Provider Demographics
NPI:1215253893
Name:ST. AUGUSTINE FOOT & ANKLE, INC.
Entity type:Organization
Organization Name:ST. AUGUSTINE FOOT & ANKLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-824-0869
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:STE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:105 SOUTHPARK BLVD
Practice Address - Street 2:STE A103
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5191
Practice Address - Country:US
Practice Address - Phone:904-824-0869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. AUGUSTINE FOOT & ANKLE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-08
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site