Provider Demographics
NPI:1326286493
Name:FAMILY FOOT CLINIC
Entity Type:Organization
Organization Name:FAMILY FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FANNIE
Authorized Official - Middle Name:RENEA
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-447-3395
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:702 PLANK RD
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0357
Mailing Address - Country:US
Mailing Address - Phone:434-447-3395
Mailing Address - Fax:
Practice Address - Street 1:702 PLANK RD
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2414
Practice Address - Country:US
Practice Address - Phone:434-447-3395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000943213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010066573Medicaid
096430001OtherCIGNA GOVERMENT SERVICES
NC890801VMedicaid
VA105423OtherANTHEM BCBS
VA26977OtherOPTIMA / SENTARA
VAU51862OtherUPIN
VA0103000943OtherLICENSE #
VA480018496OtherRAILROAD MEDICARE
VA26977OtherOPTIMA / SENTARA