Provider Demographics
NPI:1730623620
Name:FOOT & ANKLE CHAMPIONS INCD
Entity type:Organization
Organization Name:FOOT & ANKLE CHAMPIONS INCD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORPUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-475-5377
Mailing Address - Street 1:4115 CENTRALIA ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:562-857-7823
Mailing Address - Fax:310-446-1825
Practice Address - Street 1:2288 WESTWOOD BLVD
Practice Address - Street 2:100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-475-5377
Practice Address - Fax:310-446-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1215376348Medicare NSC