1467620021 NPI number — D DIABETIC FOOT CENTRE AND WALKING INSTITUTE, LLC

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 1467620021 NPI number — D DIABETIC FOOT CENTRE AND WALKING INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D DIABETIC FOOT CENTRE AND WALKING INSTITUTE, 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:
Provider Other Organization Name Type Code:
6
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:
1467620021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12745 S SAGINAW ST
Provider Second Line Business Mailing Address:
SUITE 806
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-2437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-695-6950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12745 S SAGINAW ST
Provider Second Line Business Practice Location Address:
SUITE 806
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-695-6950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
E.A.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
810-691-0971

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  5901001885 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 480B518380 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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