Provider Demographics
NPI:1699904169
Name:CERTIFIED FOOT & ANKLE SPECIALISTS
Entity type:Organization
Organization Name:CERTIFIED FOOT & ANKLE SPECIALISTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KINMON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-995-0229
Mailing Address - Street 1:1601 CLINT MOORE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-5713
Mailing Address - Country:US
Mailing Address - Phone:561-369-2199
Mailing Address - Fax:561-935-1582
Practice Address - Street 1:1601 CLINT MOORE RD STE 180
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-5713
Practice Address - Country:US
Practice Address - Phone:561-995-0229
Practice Address - Fax:561-989-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3007213ES0103X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001593100Medicaid
FLCA001AOtherMEDICARE
FL10D2092005OtherCLIA
FL0005LOtherBLUE CROSS BLUE SHIELD OF FLORIDA
FLCA001AOtherMEDICARE