MEDICARE: FOOT CARE STORE INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568057057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT CARE STORE INC

Provider Business Mailing Address
First Line	:	3281 FAIRLANE FARMS RD
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-6503
Country	:	US
Telephone Number	:	615-721-7063
Fax Number	:	561-791-9919

Provider Business Practice Location Address
First Line	:	4280 W WINDMILL LN STE 111
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-5857
Country	:	US
Telephone Number	:	561-721-7063
Fax Number	:	561-791-9919

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT MARK GAYNOR
Credential	:	DPM
Telephone Number	:	156-186-6338

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	03/05/2021

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Directions to “FOOT CARE STORE INC ” Practice Location

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