Healthcare Provider Details

I. General information

NPI: 1770991861
Provider Name (Legal Business Name): LOWER EXTREMITY DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 TARA BOULEVARD
JONESBORO GA
30236
US

IV. Provider business mailing address

6911 TARA BOULEVARD
JONESBORO GA
30236
US

V. Phone/Fax

Practice location:
  • Phone: 770-477-9535
  • Fax:
Mailing address:
  • Phone: 770-477-9535
  • Fax: 770-471-7826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberPOD000382
License Number StateGA

VIII. Authorized Official

Name: DR. STANLEY KALISH
Title or Position: MEMBER
Credential:
Phone: 770-477-9535