=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326286493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FOOT CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2009
-----------------------------------------------------
Last Update Date | 01/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 PLANK RD
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 357 702 PLANK RD
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-0357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-447-3395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. FANNIE RENEA BENNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-447-3395
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 0103000943
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------