Healthcare Provider Details

I. General information

NPI: 1558536961
Provider Name (Legal Business Name): DOMINION FOOT AND ANKLE CENTER,LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13305A MIDLOTHIAN TPKE
MIDLOTHIAN VA
23113-4211
US

IV. Provider business mailing address

PO BOX 561
MIDLOTHIAN VA
23113-0561
US

V. Phone/Fax

Practice location:
  • Phone: 804-378-1818
  • Fax: 804-378-1818
Mailing address:
  • Phone: 804-378-1818
  • Fax: 804-794-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103000786
License Number StateVA

VIII. Authorized Official

Name: DR. GEORGE KENNETH MARINO
Title or Position: PRESIDENT
Credential: DPM
Phone: 804-378-1818