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General NPI Number Information
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NPI Number | 1619078276
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Entity Type | Organization
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Legal Business Name | PRIMARY FOOT & ANKLE CARE
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 862 AMBER HILL CT
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City | GRAYSON
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State | GA
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Zip | 30017
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Country | US
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Telephone | 770-513-3556
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Fax | 770-513-3556
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Provider Business Mailing Address
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Address Line | 862 AMBER HILL CT
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City | GRAYSON
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State | GA
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Zip | 30017
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Country | US
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Telephone | 770-513-3556
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Fax | 770-513-3556
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Authorized Official
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Title or Position | PRESIDENT
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Name | TOM TIEN DANG
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Credential | DPM
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Telephone | 770-513-3556
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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 | POD000824
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License Number State | GA
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