Provider Demographics
NPI:1043399439
Name:FOOT CARE CENTER OF COLLEGE PARK, CHARTERED
Entity Type:Organization
Organization Name:FOOT CARE CENTER OF COLLEGE PARK, CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-779-0355
Mailing Address - Street 1:4511 KNOX RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3380
Mailing Address - Country:US
Mailing Address - Phone:301-779-0355
Mailing Address - Fax:301-927-7036
Practice Address - Street 1:4511 KNOX RD
Practice Address - Street 2:SUITE 103
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3380
Practice Address - Country:US
Practice Address - Phone:301-779-0355
Practice Address - Fax:301-927-7036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-04
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD952261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
9948OtherBC
T261FOOtherBCBS MD