Healthcare Provider Details

I. General information

NPI: 1891170619
Provider Name (Legal Business Name): EASTERN SHORE FAMILY FOOT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 5TH AVE
DENTON MD
21629-1368
US

IV. Provider business mailing address

6412 CHURCH HILL RD
CHESTERTOWN MD
21620-2386
US

V. Phone/Fax

Practice location:
  • Phone: 410-819-0096
  • Fax: 410-479-4622
Mailing address:
  • Phone: 410-778-1801
  • Fax: 410-758-3249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLI CLARKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 410-758-5446