Healthcare Provider Details

I. General information

NPI: 1891939682
Provider Name (Legal Business Name): GENTLE FOOT CARE OF WESTERN OHIO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 WOODWARD AVE STE 318
DETROIT MI
48201-2066
US

IV. Provider business mailing address

3800 WOODWARD AVE STE 318 SUITE 1102
DETROIT MI
48201-2066
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-3090
  • Fax: 313-833-7843
Mailing address:
  • Phone: 313-833-3090
  • Fax: 313-833-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901002275
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5901002275
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number5901002275
License Number StateMI

VIII. Authorized Official

Name: CARMEN HENDERSON
Title or Position: CREDENTIALS SPECIALIST
Credential:
Phone: 614-457-3212