Basic Information
| Provider Information | |||||||||
| NPI: | 1487706008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORELINE FOOT & ANKLE CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 POHEGANUT DR | ||||||||
| Address2: | |||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063403252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604373737 | ||||||||
| FaxNumber: | 8604370530 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 POHEGANUT DR | ||||||||
| Address2: | |||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063403252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604373737 | ||||||||
| FaxNumber: | 8604370530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | COURTRIGHT | ||||||||
| AuthorizedOfficialFirstName: | DARREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8604373737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHORELINE FOOT HEALTH CENTER, PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.