Provider Demographics
NPI:1578938684
Name:TOTAL FOOT CARE AND WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:TOTAL FOOT CARE AND WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-323-0954
Mailing Address - Street 1:8021 PHILIPS HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7460
Mailing Address - Country:US
Mailing Address - Phone:904-323-0954
Mailing Address - Fax:904-660-2125
Practice Address - Street 1:8021 PHILIPS HWY STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7460
Practice Address - Country:US
Practice Address - Phone:904-323-0954
Practice Address - Fax:904-660-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020165000Medicaid