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General NPI Number Information
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NPI Number | 1578637633
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Entity Type | Organization
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Legal Business Name | MANASSAS FOOT CLINIC INC
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 12/18/2012
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Provider Practice Location Address
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Address Line | 8704 ROLLING RD
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City | MANASSAS
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State | VA
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Zip | 20110-4253
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Country | US
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Telephone | 703-361-3132
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Fax | 703-368-0291
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Provider Business Mailing Address
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Address Line | 8704 ROLLING RD
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City | MANASSAS
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State | VA
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Zip | 20110-4253
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Country | US
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Telephone | 703-361-3132
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Fax | 703-368-0291
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICARDO M. BENNETT
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Credential | D.P.M.
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Telephone | 703-361-3132
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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 | 0103000268
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 0103001009
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License Number State | VA
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