Healthcare Provider Details

I. General information

NPI: 1578637633
Provider Name (Legal Business Name): MANASSAS FOOT CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8704 ROLLING RD
MANASSAS VA
20110-4253
US

IV. Provider business mailing address

8704 ROLLING RD
MANASSAS VA
20110-4253
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-3132
  • Fax: 703-368-0291
Mailing address:
  • Phone: 703-361-3132
  • Fax: 703-368-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103001009
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103000268
License Number StateVA

VIII. Authorized Official

Name: DR. RICARDO M. BENNETT
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 703-361-3132