Provider Demographics
NPI:1306004874
Name:BARE FOOT CARE SPECIALIST, LLC
Entity Type:Organization
Organization Name:BARE FOOT CARE SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-531-9222
Mailing Address - Street 1:3485 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-2918
Mailing Address - Country:US
Mailing Address - Phone:770-531-9222
Mailing Address - Fax:
Practice Address - Street 1:3485 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-2918
Practice Address - Country:US
Practice Address - Phone:770-531-9222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD 1075213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2771997OtherUHC
GA4384641OtherCIGNA
GA576003162BMedicaid
GA511G700542OtherMEDICARE PART B
GA52222642-004OtherBCBS
GA7861901OtherAETNA
GA6142750001Medicare NSC