Provider Demographics
NPI:1699862755
Name:SOUTHERN CALIFORNIA PODIATRY GROUP, INC.
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA PODIATRY GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-896-5899
Mailing Address - Street 1:6030 VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3088
Mailing Address - Country:US
Mailing Address - Phone:562-896-5899
Mailing Address - Fax:562-236-1283
Practice Address - Street 1:2661 E FLORENCE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4793
Practice Address - Country:US
Practice Address - Phone:323-583-4440
Practice Address - Fax:323-583-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty