Healthcare Provider Details

I. General information

NPI: 1952814717
Provider Name (Legal Business Name): PRIMARY FOOT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3004 ESTATE ALTONA
ST THOMAS VI
00802-5735
US

IV. Provider business mailing address

9160 ESTATE THOMAS
ST THOMAS VI
00802-3641
US

V. Phone/Fax

Practice location:
  • Phone: 888-499-7747
  • Fax:
Mailing address:
  • Phone: 888-499-7747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number1475
License Number StateVI

VIII. Authorized Official

Name: DR. GAIL MONICA RUCKER
Title or Position: OWNER
Credential: DPM
Phone: 888-499-7747