1083899934 NPI number — ADVANTAGE FOOT CARE, LLC

Table of content: (NPI 1083899934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083899934 NPI number — ADVANTAGE FOOT CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE 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:
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:
1083899934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LULING
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70070-1054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-331-1865
Provider Business Mailing Address Fax Number:
985-785-1445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2809 SAINT CLAUDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70117-7224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-947-3668
Provider Business Practice Location Address Fax Number:
504-947-4444
Provider Enumeration Date:
01/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TABB
Authorized Official First Name:
YACARA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
504-905-9458

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PD177R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4E162 . This is a "MEDICARE ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1685585 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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