1689934739 NPI number — ADVANCED FOOTCARE CENTER

Table of content: (NPI 1689934739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689934739 NPI number — ADVANCED FOOTCARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOTCARE CENTER
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:
1689934739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 BOSTON POST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06477-3235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-799-3668
Provider Business Mailing Address Fax Number:
203-891-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 DURHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GUILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06437-2087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-799-3668
Provider Business Practice Location Address Fax Number:
203-891-0766
Provider Enumeration Date:
05/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
203-799-3668

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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