Provider Demographics
NPI:1003986779
Name:FAMILY FOOT CARE SPECIALIST PODIATRY CENTER
Entity Type:Organization
Organization Name:FAMILY FOOT CARE SPECIALIST PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:707-725-5223
Mailing Address - Street 1:1730 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2451
Mailing Address - Country:US
Mailing Address - Phone:707-725-5223
Mailing Address - Fax:707-725-2756
Practice Address - Street 1:1730 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2451
Practice Address - Country:US
Practice Address - Phone:707-725-5223
Practice Address - Fax:707-725-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699791160 01Medicaid
CAZZZ01811ZMedicare UPIN
CA1699791160 01Medicaid