Healthcare Provider Details

I. General information

NPI: 1093382681
Provider Name (Legal Business Name): MAGNOLIA GREEN FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6055 HARBOUR PARK DR
MIDLOTHIAN VA
23112-2160
US

IV. Provider business mailing address

6055 HARBOUR PARK DR
MIDLOTHIAN VA
23112-2160
US

V. Phone/Fax

Practice location:
  • Phone: 804-500-0949
  • Fax: 804-500-0946
Mailing address:
  • Phone: 804-500-0949
  • Fax: 804-500-0946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUNGMIN YOO
Title or Position: CEO
Credential:
Phone: 804-500-0949