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General NPI Number Information
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NPI Number | 1275700205
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Entity Type | Organization
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Legal Business Name | GARDEN STATE FOOT CARE
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Dates
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Enumeration Date | 05/08/2008
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Last Update Date | 10/15/2009
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Provider Practice Location Address
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Address Line | 200 B STATE HIGHWAY 73 SUITE 3
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City | VOORHEES
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State | NJ
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Zip | 08043-9542
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Country | US
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Telephone | 856-753-1300
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Fax | 856-768-2965
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Provider Business Mailing Address
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Address Line | 200 B STATE HIGHWAY 73 SUITE 3
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City | VOORHEES
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State | NJ
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Zip | 08043-9542
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Country | US
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Telephone | 856-753-1300
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Fax | 856-768-2965
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Authorized Official
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Title or Position | OWNER
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Name | DR. LARRY L. LODGE
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Credential | DPM
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Telephone | 856-753-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 25MD002054
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License Number State | NJ
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