Provider Demographics
NPI:1538678792
Name:FANCY FEET FOOT CARE CENTER
Entity Type:Organization
Organization Name:FANCY FEET FOOT CARE CENTER
Other - Org Name:FFFCC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSAA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHYARS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-345-9535
Mailing Address - Street 1:8511 SHARONBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-5667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10716 CARMEL COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3783
Practice Address - Country:US
Practice Address - Phone:980-206-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC636213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty