Provider Demographics
NPI:1033381249
Name:AFFILIATED FOOT CARE CENTER, LLC
Entity Type:Organization
Organization Name:AFFILIATED FOOT CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-294-4977
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:STE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-9460
Practice Address - Street 1:15 S ELM ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4741
Practice Address - Country:US
Practice Address - Phone:203-294-4977
Practice Address - Fax:203-294-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000723332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4378710002Medicare NSC