Provider Demographics
NPI:1306606579
Name:CONVALESCENT PODIATRY CARE A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CONVALESCENT PODIATRY CARE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOOYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:HAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:657-200-5680
Mailing Address - Street 1:5445 DEL AMO BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2761
Mailing Address - Country:US
Mailing Address - Phone:562-867-0811
Mailing Address - Fax:562-866-4046
Practice Address - Street 1:5445 DEL AMO BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2761
Practice Address - Country:US
Practice Address - Phone:562-867-0811
Practice Address - Fax:562-866-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist