Healthcare Provider Details

I. General information

NPI: 1699791160
Provider Name (Legal Business Name): FAMILY FOOT CARE SPECIALISTS PODIATRY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 MAIN ST
FORTUNA CA
95540-2467
US

IV. Provider business mailing address

1730 MAIN ST
FORTUNA CA
95540-2467
US

V. Phone/Fax

Practice location:
  • Phone: 707-725-5223
  • Fax: 707-725-2756
Mailing address:
  • Phone: 707-725-5223
  • Fax: 707-725-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberE2321
License Number StateCA

VIII. Authorized Official

Name: MR. NEIL ROBERT KELLEY
Title or Position: OWNER/CEO
Credential: D.P.M.
Phone: 707-725-5223