Basic Information
Provider Information | |||||||||
NPI: | 1992969992 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOOT AND LEG CENTERS OF AMERICA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3556 RIVERSIDE DR | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312102509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784759250 | ||||||||
FaxNumber: | 4784757920 | ||||||||
Practice Location | |||||||||
Address1: | 3556 RIVERSIDE DR | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312102509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784759250 | ||||||||
FaxNumber: | 4784757920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2008 | ||||||||
LastUpdateDate: | 07/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VITO | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
AuthorizedOfficialTelephone: | 4784759250 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X |   | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.