Provider Demographics
NPI:1578696878
Name:PODIATRY & BAREFOOT WELLNESS CENTERS LLC
Entity Type:Organization
Organization Name:PODIATRY & BAREFOOT WELLNESS CENTERS LLC
Other - Org Name:PODIATRY CENTERS OF NORTH FLORIDA LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROSHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-389-0346
Mailing Address - Street 1:1205 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3405
Mailing Address - Country:US
Mailing Address - Phone:904-389-0346
Mailing Address - Fax:904-246-5449
Practice Address - Street 1:1205 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3405
Practice Address - Country:US
Practice Address - Phone:904-389-0346
Practice Address - Fax:904-246-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390197100Medicaid
FL390197100Medicaid
FL1083120001Medicare NSC
FL72446Medicare PIN