1043399439 NPI number — FOOT CARE CENTER OF COLLEGE PARK, CHARTERED

Table of content: (NPI 1043399439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043399439 NPI number — FOOT CARE CENTER OF COLLEGE PARK, CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT CARE CENTER OF COLLEGE PARK, CHARTERED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043399439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4511 KNOX RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
COLLEGE PARK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20740-3380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-779-0355
Provider Business Mailing Address Fax Number:
301-927-7036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4511 KNOX RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20740-3380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-779-0355
Provider Business Practice Location Address Fax Number:
301-927-7036
Provider Enumeration Date:
11/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
MARC
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
301-779-0355

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  952 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9948 . This is a "BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: T261FO . This is a "BCBS MD" identifier . This identifiers is of the category "OTHER".




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