1073557799 NPI number — PRIME FOOT CARE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073557799 NPI number — PRIME FOOT CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME FOOT CARE, PLLC
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:
DESOTO FOOT CARE
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:
1073557799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9065 SANDIDGE CENTER COVE
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
OLIVE BRANCH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38654-3574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-893-0533
Provider Business Mailing Address Fax Number:
662-890-5676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9065 SANDIDGE CENTER COVE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-3574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-893-0533
Provider Business Practice Location Address Fax Number:
662-985-6821
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
ARNETTE
Authorized Official Title or Position:
PODTIATRIST
Authorized Official Telephone Number:
662-893-0533

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  80159 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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