Provider Demographics
NPI:1053358473
Name:INLAND EMPIRE FOOT DOCTORS, INC
Entity type:Organization
Organization Name:INLAND EMPIRE FOOT DOCTORS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:951-243-7771
Mailing Address - Street 1:23110 ATLANTIC CIR
Mailing Address - Street 2:SUITE F
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5920
Mailing Address - Country:US
Mailing Address - Phone:951-243-7771
Mailing Address - Fax:951-924-1621
Practice Address - Street 1:23110 ATLANTIC CIR
Practice Address - Street 2:SUITE F
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5920
Practice Address - Country:US
Practice Address - Phone:951-243-7771
Practice Address - Fax:951-924-1621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4159213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01637ZMedicare ID - Type Unspecified