Basic Information
| Provider Information | |||||||||
| NPI: | 1821393422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST TENNESSEE FOOT CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 US HIGHWAY 51 BYP E | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312873130 | ||||||||
| FaxNumber: | 7312873818 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 ASBURY AVE | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | RIPLEY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380635577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312212567 | ||||||||
| FaxNumber: | 7312212560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2011 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | LU | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7312873130 | ||||||||
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| 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 | 213ES0131X | 0000000658 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.