Healthcare Provider Details

I. General information

NPI: 1508029604
Provider Name (Legal Business Name): GOLDEN FOOTPRINT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S BRAGG ST SUITE 6
WARRENTON NC
27589-2048
US

IV. Provider business mailing address

718 N HARRISON AVE
CARY NC
27513-5431
US

V. Phone/Fax

Practice location:
  • Phone: 919-271-8146
  • Fax: 919-460-0776
Mailing address:
  • Phone: 919-271-8146
  • Fax: 919-460-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LEONARD SMITH
Title or Position: CEO
Credential:
Phone: 919-271-8146