Provider Demographics
NPI:1043773914
Name:FOOT AND ANKLE RECONSTRUCTION CENTER OF GEORGIA LLC
Entity Type:Organization
Organization Name:FOOT AND ANKLE RECONSTRUCTION CENTER OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DARRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-477-4445
Mailing Address - Street 1:1025 E FREEWAY DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5965
Mailing Address - Country:US
Mailing Address - Phone:770-929-3338
Mailing Address - Fax:770-760-7942
Practice Address - Street 1:1025 E FREEWAY DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5965
Practice Address - Country:US
Practice Address - Phone:937-477-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty