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General NPI Number Information
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NPI Number | 1548662935
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Entity Type | Organization
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Legal Business Name | PERSONAL FOOT CARE II, LLC
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 11/17/2014
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Provider Practice Location Address
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Address Line | 2020 WAKEFIELD AVE
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City | PETERSBURG
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State | VA
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Zip | 23805-2112
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Country | US
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Telephone | 804-732-1211
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Fax | 804-733-5946
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Provider Business Mailing Address
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Address Line | 2020 WAKEFIELD AVE
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City | PETERSBURG
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State | VA
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Zip | 23805-2112
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Country | US
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Telephone | 804-732-1211
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Fax | 804-733-5946
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Authorized Official
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Title or Position | OWNER
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Name | DR. SAMUEL W PERSON
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Credential | DPM
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Telephone | 804-732-1211
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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 | 0103301109
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License Number State | VA
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