Provider Demographics
NPI:1609524487
Name:GEORGIA DOCTORS FOOT & LEG CENTER, LLC
Entity Type:Organization
Organization Name:GEORGIA DOCTORS FOOT & LEG CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUPRIHATIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSHIOKPEKHAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-328-6466
Mailing Address - Street 1:1533 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3449
Mailing Address - Country:US
Mailing Address - Phone:478-328-6466
Mailing Address - Fax:478-328-1338
Practice Address - Street 1:940 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4059
Practice Address - Country:US
Practice Address - Phone:478-254-4026
Practice Address - Fax:478-254-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000737492EMedicaid