Healthcare Provider Details

I. General information

NPI: 1053400176
Provider Name (Legal Business Name): FOOT HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 S MAIN ST
CHESHIRE CT
06410-3448
US

IV. Provider business mailing address

714 S MAIN ST
CHESHIRE CT
06410-3448
US

V. Phone/Fax

Practice location:
  • Phone: 203-271-0556
  • Fax: 203-250-9951
Mailing address:
  • Phone: 203-271-0556
  • Fax: 203-250-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number395
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number395
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL J ACKLEY
Title or Position: PODIATRIST, OWNER
Credential: DPM
Phone: 203-271-0556