Healthcare Provider Details

I. General information

NPI: 1437144896
Provider Name (Legal Business Name): GREENVILLE FOOT & ANKLE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 S CHARLES BLVD
GREENVILLE NC
27858-5925
US

IV. Provider business mailing address

2409 S CHARLES BLVD
GREENVILLE NC
27858-5925
US

V. Phone/Fax

Practice location:
  • Phone: 252-321-0203
  • Fax: 252-353-5669
Mailing address:
  • Phone: 252-321-0203
  • Fax: 252-353-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number239
License Number StateNC

VIII. Authorized Official

Name: PAUL J CIVATTE
Title or Position: MEMBER/MANAGER
Credential: DPM
Phone: 252-321-0203