MEDICARE: FOOT CLINIC OF LOUISIANA 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	261QP1100X	Podiatric Clinic/Center

General Provider Information

NPI Number	:	1194083220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT CLINIC OF LOUISIANA INC

Provider Business Mailing Address
First Line	:	4860 BLUEBONNET BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-9644
Country	:	US
Telephone Number	:	225-295-1027
Fax Number	:	225-295-1491

Provider Business Practice Location Address
First Line	:	2000 AUDUBON AVE
Second Line	:	SUITE C-1
City	:	THIBODAUX
State	:	LA
Zip	:	70301-5075
Country	:	US
Telephone Number	:	985-446-2335
Fax Number	:	985-446-2337

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSEPH KEMP TULLIER
Credential	:	DPM
Telephone Number	:	225-295-1027

Provider Enumeration Date	:	04/26/2012
Last Update Date	:	03/13/2014

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