Provider Demographics
NPI:1497957120
Name:ADVANCED FOOT CARE CENTER
Entity Type:Organization
Organization Name:ADVANCED FOOT CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-981-3001
Mailing Address - Street 1:4510 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6016
Mailing Address - Country:US
Mailing Address - Phone:601-981-3001
Mailing Address - Fax:601-981-8999
Practice Address - Street 1:4510 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-6016
Practice Address - Country:US
Practice Address - Phone:601-981-3001
Practice Address - Fax:601-981-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80152213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09274794Medicaid
MS09274794Medicaid
MS09274794Medicaid