Provider Demographics
NPI:1497832489
Name:CHARLIES FOOTCARE & MEDICAL SUPPLY INC.
Entity Type:Organization
Organization Name:CHARLIES FOOTCARE & MEDICAL SUPPLY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:JACQUELYN
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:ABC/CO/BOCO/LO-FL
Authorized Official - Phone:615-848-1381
Mailing Address - Street 1:416 MEDICAL CENTER PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2753
Mailing Address - Country:US
Mailing Address - Phone:615-848-1381
Mailing Address - Fax:615-848-0717
Practice Address - Street 1:416 MEDICAL CENTER PKWY STE C
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2753
Practice Address - Country:US
Practice Address - Phone:615-848-1381
Practice Address - Fax:615-848-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452383Medicaid
TN4080266OtherBLUE CROSS BLUE SHEILD
TN5132310001Medicare ID - Type Unspecified