Provider Demographics
NPI:1447427562
Name:REALITY FOOT CARE LLC
Entity Type:Organization
Organization Name:REALITY FOOT CARE LLC
Other - Org Name:HEALTHY FEET STORE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:817-377-3668
Mailing Address - Street 1:2921 LACKLAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-4173
Mailing Address - Country:US
Mailing Address - Phone:817-377-3668
Mailing Address - Fax:817-377-2646
Practice Address - Street 1:2921 LACKLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-4173
Practice Address - Country:US
Practice Address - Phone:817-377-3668
Practice Address - Fax:817-377-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCPED1950261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010258401Medicaid
TX6421840001Medicare NSC