MEDICARE: SOUTH SIDE FOOT CLINIC

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	332B00000X	Durable Medical Equipment & Medical Supplies		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700014214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH SIDE FOOT CLINIC

Provider Business Mailing Address
First Line	:	4759 SOUTH FWY STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3655
Country	:	US
Telephone Number	:	817-923-1953
Fax Number	:	817-923-9615

Provider Business Practice Location Address
First Line	:	4759 SOUTH FWY STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3655
Country	:	US
Telephone Number	:	817-923-1953
Fax Number	:	817-923-9615

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. VICKIE KHANNA
Credential	:	DPM
Telephone Number	:	817-923-1953

Provider Enumeration Date	:	06/24/2009
Last Update Date	:	06/24/2009

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Directions to “SOUTH SIDE FOOT CLINIC ” Practice Location

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