MEDICARE: FOOTHEALS PROSTHETICS AND ORTHOTICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier		TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4145147	OTHER	TN	BCBS OF TN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124101373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHEALS PROSTHETICS AND ORTHOTICS, INC.

Provider Business Mailing Address
First Line	:	2406 SUSANNAH ST
Second Line	:	LOWER LEVEL
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1725
Country	:	US
Telephone Number	:	423-975-5462
Fax Number	:	423-975-5463

Provider Business Practice Location Address
First Line	:	2406 SUSANNAH ST
Second Line	:	LOWER LEVEL
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1725
Country	:	US
Telephone Number	:	423-975-5462
Fax Number	:	423-975-5463

Authorized Official
Title or Position	:	PROTHETIST, ORTHOTIST,, PEDORTHIST
Name	:	MR. CALVIN K HOYLE
Credential	:	CP, BOCO, CPED
Telephone Number	:	423-975-5462

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	04/08/2008

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