Healthcare Provider Details

I. General information

NPI: 1609524487
Provider Name (Legal Business Name): GEORGIA DOCTORS FOOT & LEG CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 PIO NONO AVE
MACON GA
31204-4059
US

IV. Provider business mailing address

1533 WATSON BLVD
WARNER ROBINS GA
31093-3449
US

V. Phone/Fax

Practice location:
  • Phone: 478-254-4026
  • Fax: 478-254-4031
Mailing address:
  • Phone: 478-328-6466
  • Fax: 478-328-1338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUPRIHATIN OSHIOKPEKHAI
Title or Position: OFFICE MANAGER
Credential:
Phone: 478-328-6466