MEDICARE: CHATEAU FOOT AND ANKLE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	POD000569	GA

General Provider Information

NPI Number	:	1134568124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHATEAU FOOT AND ANKLE CENTER, LLC

Provider Business Mailing Address
First Line	:	1515 RIVER PL
Second Line	:	SUITE 140
City	:	BRASELTON
State	:	GA
Zip	:	30517-5602
Country	:	US
Telephone Number	:	770-648-5040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 RIVER PL
Second Line	:	SUITE 140
City	:	BRASELTON
State	:	GA
Zip	:	30517-5602
Country	:	US
Telephone Number	:	770-648-5040
Fax Number	:

Authorized Official
Title or Position	:	PODIATRIST-OWNER
Name	:	DR. BRADLEY DAVID CASTELLANO
Credential	:	D.P.M.
Telephone Number	:	770-648-5040

Provider Enumeration Date	:	06/23/2013
Last Update Date	:	01/20/2015

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