Provider Demographics
NPI:1225148018
Name:FOOTCARE STORE INC
Entity Type:Organization
Organization Name:FOOTCARE STORE INC
Other - Org Name:DIA-FOOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAYNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-641-2647
Mailing Address - Street 1:6316 LANTANA RD
Mailing Address - Street 2:SUITE 34
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-6679
Mailing Address - Country:US
Mailing Address - Phone:561-641-2647
Mailing Address - Fax:561-642-1590
Practice Address - Street 1:6316 LANTANA RD
Practice Address - Street 2:SUITE 34
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-6679
Practice Address - Country:US
Practice Address - Phone:561-641-2647
Practice Address - Fax:561-642-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4036910001OtherDME #