Healthcare Provider Details

I. General information

NPI: 1598657504
Provider Name (Legal Business Name): BOARD CERTIFIED FOOTCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BOSTON POST RD
SUDBURY MA
01776-2463
US

IV. Provider business mailing address

111 BOSTON POST RD
SUDBURY MA
01776-2463
US

V. Phone/Fax

Practice location:
  • Phone: 978-443-4878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: OMID NAVID EBRAHIMI-SOHI
Title or Position: MANAGER
Credential:
Phone: 214-504-4126