=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366637399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT AND ANKLE WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 PIRKLE FERRY RD STE J500
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-9221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-513-8777
-----------------------------------------------------
Fax | 678-513-8999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 PIRKLE FERRY RD STE J500
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-9221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-513-8777
-----------------------------------------------------
Fax | 678-513-8999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEITH MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-513-8777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | GA000916
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------