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General NPI Number Information
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NPI Number | 1972532125
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Entity Type | Organization
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Legal Business Name | CLAY COUNTY PODIATRY, LLC
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 05/31/2019
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Provider Practice Location Address
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Address Line | 955 W CRAIG AVE
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City | BRAZIL
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State | IN
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Zip | 47834-7400
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Country | US
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Telephone | 812-448-9290
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Fax | 812-448-9296
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Provider Business Mailing Address
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Address Line | 955 W CRAIG AVE
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City | BRAZIL
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State | IN
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Zip | 47834-7400
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Country | US
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Telephone | 812-448-9290
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Fax | 812-448-9296
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. MIRANDA ANNE GOODALE
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Credential | DPM
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Telephone | 812-448-9290
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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 | 07001015A
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License Number State | IN
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