Healthcare Provider Details

I. General information

NPI: 1881869535
Provider Name (Legal Business Name): CAROLINA FAMILY FOOT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3396 SIX FORKS RD
RALEIGH NC
27609-7233
US

IV. Provider business mailing address

122 N MAIN ST
FUQUAY VARINA NC
27526-1934
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-8124
  • Fax: 919-557-5645
Mailing address:
  • Phone: 919-557-5148
  • Fax: 919-557-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOHN P MIKETA
Title or Position: OWNER
Credential: DPM
Phone: 919-557-5148