Healthcare Provider Details

I. General information

NPI: 1508155037
Provider Name (Legal Business Name): EASY WALK FOOT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BECKETT LN SUITE 104
FAYETTEVILLE GA
30214-7155
US

IV. Provider business mailing address

3364 MEDINA DR
JONESBORO GA
30236-6873
US

V. Phone/Fax

Practice location:
  • Phone: 678-489-6589
  • Fax: 678-489-6522
Mailing address:
  • Phone: 646-489-6589
  • Fax: 678-489-6522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001142
License Number StateGA

VIII. Authorized Official

Name: DR. AZUKA IFEYINWA NWAEDOZIE
Title or Position: PODIATRIST/OWNER
Credential: D.P.M
Phone: 678-489-6589