=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578696878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PODIATRY & BAREFOOT WELLNESS CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 BEACH BLVD
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-389-0346
-----------------------------------------------------
Fax | 904-246-5449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 BEACH BLVD
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-389-0346
-----------------------------------------------------
Fax | 904-246-5449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DIRECTOR
-----------------------------------------------------
Name | DR. HOWARD J GROSHELL
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 904-389-0346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------