Healthcare Provider Details

I. General information

NPI: 1396874285
Provider Name (Legal Business Name): BRUNSWICK FOOT & ANKLE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOCTORS CIR SUITE 2
SUPPLY NC
28462-4097
US

IV. Provider business mailing address

14 DOCTORS CIR SUITE 2
SUPPLY NC
28462-4097
US

V. Phone/Fax

Practice location:
  • Phone: 919-751-9120
  • Fax: 919-751-9170
Mailing address:
  • Phone: 919-751-9120
  • Fax: 919-751-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number452
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH KIBLER
Title or Position: OWNER
Credential: DPM
Phone: 919-751-9120