Provider Demographics
NPI:1649964255
Name:SOUTH BAY PODIATRY OFFICE INC
Entity type:Organization
Organization Name:SOUTH BAY PODIATRY OFFICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRIT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUTANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-620-2493
Mailing Address - Street 1:2407 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1528
Mailing Address - Country:US
Mailing Address - Phone:323-620-2493
Mailing Address - Fax:
Practice Address - Street 1:2407 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-1528
Practice Address - Country:US
Practice Address - Phone:323-620-2493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty