Healthcare Provider Details

I. General information

NPI: 1790883056
Provider Name (Legal Business Name): ALLEN PARK FOOTCARE SPECIALIST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19250 ECORSE RD
ALLEN PARK MI
48101-2260
US

IV. Provider business mailing address

19250 ECORSE RD
ALLEN PARK MI
48101-2260
US

V. Phone/Fax

Practice location:
  • Phone: 313-294-9700
  • Fax: 313-294-9700
Mailing address:
  • Phone: 313-294-9700
  • Fax: 313-294-9700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number5901001699
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5901001699
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901001699
License Number StateMI

VIII. Authorized Official

Name: DR. BRIAN E HOMER
Title or Position: OWNER
Credential: D.P.M, P.C.
Phone: 248-288-8900