Provider Demographics
NPI:1568057057
Name:FOOT CARE STORE INC
Entity Type:Organization
Organization Name:FOOT CARE STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:156-186-6338
Mailing Address - Street 1:3281 FAIRLANE FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6503
Mailing Address - Country:US
Mailing Address - Phone:615-721-7063
Mailing Address - Fax:561-791-9919
Practice Address - Street 1:4280 W WINDMILL LN STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-5857
Practice Address - Country:US
Practice Address - Phone:561-721-7063
Practice Address - Fax:561-791-9919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT CARE STORE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029761500Medicaid