Provider Demographics
NPI:1073059507
Name:CHARLOTTE COUNTY FOOT CLINICS LLC
Entity Type:Organization
Organization Name:CHARLOTTE COUNTY FOOT CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-479-0481
Mailing Address - Street 1:2866 TAMIAMI TRL
Mailing Address - Street 2:STE C
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5126
Mailing Address - Country:US
Mailing Address - Phone:941-629-3535
Mailing Address - Fax:941-625-2076
Practice Address - Street 1:2866 TAMIAMI TRL
Practice Address - Street 2:STE C
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5126
Practice Address - Country:US
Practice Address - Phone:941-629-3535
Practice Address - Fax:941-625-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-08
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3373213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty