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General NPI Number Information
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NPI Number | 1699958421
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Entity Type | Organization
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Legal Business Name | RIVERDALE FOOT, ANKLE AND LEG CLINIC
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Dates
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Enumeration Date | 12/15/2007
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Last Update Date | 01/08/2009
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Provider Practice Location Address
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Address Line | 6567 PROFESSIONAL PL
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City | RIVERDALE
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State | GA
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Zip | 30274-2519
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Country | US
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Telephone | 770-997-3668
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Fax | 770-997-3470
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Provider Business Mailing Address
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Address Line | 6567 PROFESSIONAL PL
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City | RIVERDALE
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State | GA
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Zip | 30274-2519
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Country | US
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Telephone | 770-997-3668
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Fax | 770-997-3470
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. TERRY LEE DICKERSON
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Credential | DPM
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Telephone | 770-997-3668
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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 | 000890
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License Number State | GA
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