Healthcare Provider Details

I. General information

NPI: 1396050449
Provider Name (Legal Business Name): FAMILY FOOT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 HORIZON RD STE 100
ROCKWALL TX
75032-7809
US

IV. Provider business mailing address

1675 REPUBLIC PKWY STE 101
MESQUITE TX
75150-6903
US

V. Phone/Fax

Practice location:
  • Phone: 972-772-9600
  • Fax: 972-772-9601
Mailing address:
  • Phone: 972-270-7627
  • Fax: 972-270-7759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0425
License Number StateTX

VIII. Authorized Official

Name: MR. MICHAEL J MILLER
Title or Position: PRESIDENT
Credential: DPM
Phone: 972-270-7627