1982067401 NPI number — QUINTESSENTIAL FOOT CARE, PLLC

Table of content: (NPI 1982067401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982067401 NPI number — QUINTESSENTIAL FOOT CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUINTESSENTIAL 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:
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:
1982067401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4758 LONGVIEW RUN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30035-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
332-331-2739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4758 LONGVIEW RUN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30035-6001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
332-331-2739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
QUINTERO
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
332-331-2739

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  006651 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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