Provider Demographics
NPI:1114315165
Name:NOURISH FOOT CARE LLC
Entity Type:Organization
Organization Name:NOURISH FOOT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DANZEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-469-2432
Mailing Address - Street 1:8640 PHILIPS HWY
Mailing Address - Street 2:STE 10
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1207
Mailing Address - Country:US
Mailing Address - Phone:904-469-2432
Mailing Address - Fax:904-779-3348
Practice Address - Street 1:8640 PHILIPS HWY
Practice Address - Street 2:STE 10
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-1207
Practice Address - Country:US
Practice Address - Phone:904-469-2432
Practice Address - Fax:904-779-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017367800Medicaid
FLDV4679Medicare PIN
FL017367800Medicaid
FLIA766AMedicare PIN