Healthcare Provider Details

I. General information

NPI: 1760870323
Provider Name (Legal Business Name): AZALEA COAST PODIATRY AND FOOT SPA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 PHYSICIANS DR SUITE 105
WILMINGTON NC
28401-7362
US

IV. Provider business mailing address

1604 PHYSICIANS DR SUITE 105
WILMINGTON NC
28401-7362
US

V. Phone/Fax

Practice location:
  • Phone: 910-777-9054
  • Fax: 910-256-6039
Mailing address:
  • Phone: 910-777-9054
  • Fax: 910-256-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number509
License Number StateNC

VIII. Authorized Official

Name: KERRY ALLYSON SMITH
Title or Position: MEMBER/MANAGER
Credential: DPM
Phone: 910-777-9054