Provider Demographics
NPI:1205019718
Name:FAMILY FOOT CARE CLINIC INC
Entity Type:Organization
Organization Name:FAMILY FOOT CARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:CALVERT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:662-837-6083
Mailing Address - Street 1:PO BOX 693
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-0693
Mailing Address - Country:US
Mailing Address - Phone:662-837-6083
Mailing Address - Fax:
Practice Address - Street 1:713 TERRY ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1353
Practice Address - Country:US
Practice Address - Phone:662-837-6083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0111506Medicaid
MSP00619619Medicare PIN