Healthcare Provider Details

I. General information

NPI: 1518231323
Provider Name (Legal Business Name): TRI CO PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6392 S. BIG A RD
TOCCOA GA
30577-9375
US

IV. Provider business mailing address

PO BOX 1266
TOCCOA GA
30577
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-5092
  • Fax: 706-282-5095
Mailing address:
  • Phone: 706-282-5092
  • Fax: 706-282-5095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD000724
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00629197B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOSEPH F DEBOSKEY DPM
Title or Position: MEMBER
Credential: DPM
Phone: 706-282-5092