Healthcare Provider Details

I. General information

NPI: 1447276639
Provider Name (Legal Business Name): FOOTLOGIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E WALKER ST
EAST FLAT ROCK NC
28726-2235
US

IV. Provider business mailing address

107 E WALKER ST
EAST FLAT ROCK NC
28726-2235
US

V. Phone/Fax

Practice location:
  • Phone: 828-697-0048
  • Fax: 828-698-6882
Mailing address:
  • Phone: 828-697-0048
  • Fax: 828-698-6882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN LYNN WIGGEN II
Title or Position: OWNER
Credential: BOCO, CO
Phone: 828-697-0048