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General NPI Number Information
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NPI Number | 1760766489
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Entity Type | Organization
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Legal Business Name | ADVANCED FOOT AND ANKLE CENTER LLC
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 09/29/2011
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Provider Practice Location Address
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Address Line | 3901 HOUMA BLVD SUITE 108
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City | METAIRIE
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State | LA
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Zip | 70006-2930
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Country | US
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Telephone | 504-451-2469
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Fax |
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Provider Business Mailing Address
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Address Line | 3901 HOUMA BLVD SUITE 108
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City | METAIRIE
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State | LA
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Zip | 70006-2930
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Country | US
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Telephone | 504-451-2469
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Fax |
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Authorized Official
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Title or Position | COPRESIDENT
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Name | DR. JOHN GIBSON FASICK
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Credential | DPM
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Telephone | 504-451-2469
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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 | PD284R
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License Number State | LA
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