Provider Demographics
NPI:1508080417
Name:ANKLE AND FOOT CENTER OF GEORGIA,LLC
Entity Type:Organization
Organization Name:ANKLE AND FOOT CENTER OF GEORGIA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOLLSTROM
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-755-1949
Mailing Address - Street 1:1555 DOCTORS DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4132
Mailing Address - Country:US
Mailing Address - Phone:770-755-1949
Mailing Address - Fax:770-783-0294
Practice Address - Street 1:2700 HIGHWAY 34 E
Practice Address - Street 2:BLDG 200
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2315
Practice Address - Country:US
Practice Address - Phone:770-755-1949
Practice Address - Fax:770-783-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6559Medicare ID - Type Unspecified