1447427562 NPI number — REALITY FOOT CARE LLC

Table of content: (NPI 1447427562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447427562 NPI number — REALITY FOOT CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REALITY FOOT CARE LLC
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:
HEALTHY FEET STORE
Provider Other Organization Name Type Code:
4
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:
1447427562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2921 LACKLAND RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76116-4173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-377-3668
Provider Business Mailing Address Fax Number:
817-377-2646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2921 LACKLAND RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76116-4173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-377-3668
Provider Business Practice Location Address Fax Number:
817-377-2646
Provider Enumeration Date:
05/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-377-3668

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  CPED1950 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010258401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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