1053400176 NPI number — FOOT HEALTH CENTER, LLC

Table of content: (NPI 1053400176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053400176 NPI number — FOOT HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT HEALTH CENTER, 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:
MEDICARE NSC
Provider Other Organization Name Type Code:
3
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:
1053400176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESHIRE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06410-3448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-271-0556
Provider Business Mailing Address Fax Number:
203-250-9951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESHIRE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06410-3448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-271-0556
Provider Business Practice Location Address Fax Number:
203-250-9951
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ACKLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PODIATRIST, OWNER
Authorized Official Telephone Number:
203-271-0556

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  395 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 395 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 787023 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 129286 . This is a "FIRST CHOICE PREF ONE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4068714 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030000395CT01 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2721297 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0542290 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 129286 . This is a "WELLCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V1300 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 480028957 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NHS221 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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