Provider Demographics
NPI:1679051932
Name:PACIFIC POINT PODIATRY INC
Entity type:Organization
Organization Name:PACIFIC POINT PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-708-1110
Mailing Address - Street 1:243 GREEN VALLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3133
Mailing Address - Country:US
Mailing Address - Phone:831-288-3400
Mailing Address - Fax:877-345-6920
Practice Address - Street 1:243 GREEN VALLEY RD STE A
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3133
Practice Address - Country:US
Practice Address - Phone:831-288-3400
Practice Address - Fax:877-345-6920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5256213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1811282494OtherINDIVIDUAL