Healthcare Provider Details

I. General information

NPI: 1518227669
Provider Name (Legal Business Name): ADVANCED FOOTCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MAIN ST
EAST HAVEN CT
06512-3003
US

IV. Provider business mailing address

109 BOSTON POST RD
ORANGE CT
06477-3235
US

V. Phone/Fax

Practice location:
  • Phone: 203-799-3668
  • Fax: 203-891-0766
Mailing address:
  • Phone: 203-799-3668
  • Fax: 203-891-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MS. AMY KELLY
Title or Position: BILLING MANAGER
Credential:
Phone: 203-799-3668