Healthcare Provider Details

I. General information

NPI: 1437324498
Provider Name (Legal Business Name): ALLIED ANKLE & FOOTCARE CENTERS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 UPPER RIVERDALE RD SUITE 203
RIVERDALE GA
30274
US

IV. Provider business mailing address

PO BOX 491658
LAWRENCEVILLE GA
30049-0028
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-7973
  • Fax: 770-907-7975
Mailing address:
  • Phone: 770-255-0424
  • Fax: 770-255-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000418
License Number StateGA

VIII. Authorized Official

Name: JAMES LOUIS BOUCHARD
Title or Position: MEDICAL DIRECTOR
Credential: DPM
Phone: 770-255-0424