Provider Demographics
NPI:1508384892
Name:ELDRIDGE PODIATRY AND DIABETES CENTER, LLC
Entity Type:Organization
Organization Name:ELDRIDGE PODIATRY AND DIABETES CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHEREE
Authorized Official - Middle Name:SHANTELL
Authorized Official - Last Name:ELDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-736-7198
Mailing Address - Street 1:1000 BARONE AVE NE APT 6308
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1871
Mailing Address - Country:US
Mailing Address - Phone:205-422-6419
Mailing Address - Fax:
Practice Address - Street 1:910 DANNON VW SW STE 2201
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2156
Practice Address - Country:US
Practice Address - Phone:404-736-7198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001267261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric