Basic Information
| Provider Information | |||||||||
| NPI: | 1760538995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANKLE AND FOOT CENTER OF GEORGIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 DOCTORS DR | ||||||||
| Address2: | STE 106 | ||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302404132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068459370 | ||||||||
| FaxNumber: | 7068459371 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301174460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708384151 | ||||||||
| FaxNumber: | 7708384887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLLSTROM,JR | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7708384151 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.