=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073059507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLOTTE COUNTY FOOT CLINICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2017
-----------------------------------------------------
Last Update Date | 01/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2866 TAMIAMI TRL STE C
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-3535
-----------------------------------------------------
Fax | 941-625-2076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2866 TAMIAMI TRL STE C
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-3535
-----------------------------------------------------
Fax | 941-625-2076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MIKE A BUSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-479-0481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO3373
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------