Provider Demographics
NPI:1700133931
Name:MICHAEL L WACH DPM PODIATRY CORP
Entity type:Organization
Organization Name:MICHAEL L WACH DPM PODIATRY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-749-6950
Mailing Address - Street 1:82935 AVENUE 48 STE 102
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6757
Mailing Address - Country:US
Mailing Address - Phone:801-878-9321
Mailing Address - Fax:801-878-9382
Practice Address - Street 1:82935 AVENUE 48 STE 102
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6757
Practice Address - Country:US
Practice Address - Phone:801-878-9321
Practice Address - Fax:801-878-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4125213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty