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General NPI Number Information
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NPI Number | 1205980232
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Entity Type | Organization
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Legal Business Name | SOUTH SIDE FOOT CLINIC INC.
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 10/10/2013
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Provider Practice Location Address
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Address Line | 4759 SOUTH FWY SUITE B
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City | FORT WORTH
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State | TX
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Zip | 76115-3655
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Country | US
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Telephone | 817-923-1953
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Fax | 817-923-9615
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Provider Business Mailing Address
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Address Line | 4759 SOUTH FWY SUITE B
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City | FORT WORTH
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State | TX
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Zip | 76115-3655
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Country | US
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Telephone | 817-923-1953
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Fax | 817-923-9615
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Authorized Official
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Title or Position | SECRETARY
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Name | DR. VICKIE KHANNA
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Credential |
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Telephone | 817-923-1953
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number |
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License Number State |
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