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General NPI Number Information
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NPI Number | 1457480683
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Entity Type | Organization
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Legal Business Name | WOLF RIVER FAMILY FOOTCARE PLLC
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 06/05/2008
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Provider Practice Location Address
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Address Line | 7424 US HIGHWAY 64 SUITE 119
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City | BARTLETT
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State | TN
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Zip | 38133-3986
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Country | US
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Telephone | 901-381-2800
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Fax | 901-381-2677
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Provider Business Mailing Address
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Address Line | 7424 US HIGHWAY 64 SUITE 119
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City | BARTLETT
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State | TN
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Zip | 38133-3986
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Country | US
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Telephone | 901-381-2800
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Fax | 901-381-2677
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Authorized Official
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Title or Position | OWNER SOLE MEMBER
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Name | DR. CARL JOSEPH SICILIANO
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Credential | D.P.M.
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Telephone | 901-381-2800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DPM0000000422
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License Number State | TN
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