Healthcare Provider Details

I. General information

NPI: 1619112968
Provider Name (Legal Business Name): SOUTHERN PODIATRY FOOT AND ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 LAKE PEHAMA TRAIL
HOMER GA
30547
US

IV. Provider business mailing address

212 LAKE PEHAMA TRAIL
HOMER GA
30547
US

V. Phone/Fax

Practice location:
  • Phone: 312-752-7713
  • Fax:
Mailing address:
  • Phone: 312-752-7713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5981134
License Number StateTN

VIII. Authorized Official

Name: RICK THORNTON
Title or Position: OWNER
Credential: DMP
Phone: 312-752-7713