Provider Demographics
NPI:1215348461
Name:ADVANCED FOOT CLINIC, INC.
Entity type:Organization
Organization Name:ADVANCED FOOT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LAVIGNA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-463-3888
Mailing Address - Street 1:2844 SUMMIT ST STE 107
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3641
Mailing Address - Country:US
Mailing Address - Phone:510-463-3888
Mailing Address - Fax:510-433-0130
Practice Address - Street 1:2844 SUMMIT ST STE 107
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3641
Practice Address - Country:US
Practice Address - Phone:510-463-3888
Practice Address - Fax:510-433-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3779213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty