Provider Demographics
NPI:1386036234
Name:DE LA SOLE PODIATRIC MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:DE LA SOLE PODIATRIC MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIANA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-606-7449
Mailing Address - Street 1:10507 OBSERVATORY PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-8511
Mailing Address - Country:US
Mailing Address - Phone:404-606-7449
Mailing Address - Fax:
Practice Address - Street 1:10507 OBSERVATORY PL
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-8511
Practice Address - Country:US
Practice Address - Phone:404-606-7449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01544213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty