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General NPI Number Information
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NPI Number | 1154568582
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Entity Type | Organization
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Legal Business Name | SOUTHEAST PODIATRY
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Dates
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Enumeration Date | 01/07/2009
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 3225 SHALLOWFORD RD SUITE 200
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City | MARIETTA
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State | GA
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Zip | 30062-1266
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Country | US
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Telephone | 770-675-7904
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Fax | 770-675-7906
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Provider Business Mailing Address
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Address Line | 3225 SHALLOWFORD RD SUITE 200
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City | MARIETTA
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State | GA
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Zip | 30062-1266
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Country | US
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Telephone | 770-675-7904
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Fax | 770-675-7906
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. SUZANNE MARIE CLOUS
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Credential | D.P.M.
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Telephone | 770-852-7035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | POD001011
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | POD001011
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License Number State | GA
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