Organization
RUSSELL A. GROOTEGOED DPM
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RUSSELL A. GROOTEGOED D.P.M (PODIATRIST)
(310) 833-3583
Entity
Organization
Contact information
Practice address
601 W 9TH ST, SAN PEDRO, CA 90731-3107
(310) 833-3583
Mailing address
601 W 9TH ST, SAN PEDRO, CA 90731-3107
(310) 833-3583
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
E2064
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000E2064000
—
CA
Enumeration date
12/09/2007
Last updated
04/20/2008
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