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General NPI Number Information
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NPI Number | 1811538390
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Entity Type | Organization
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Legal Business Name | MODERN PODIATRY, LLC
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Dates
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Enumeration Date | 10/04/2019
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Last Update Date | 05/13/2024
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Provider Practice Location Address
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Address Line | 366 RACETRACK RD
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City | MCDONOUGH
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State | GA
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Zip | 30252-1022
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Country | US
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Telephone | 470-781-5585
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Fax |
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Provider Business Mailing Address
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Address Line | 1270 HIGHWAY 314
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-5449
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Country | US
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Telephone | 813-300-4449
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIBIBI WANZU
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Credential | DPM
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Telephone | 470-781-5585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number |
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License Number State |
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