Provider Demographics
NPI:1629388160
Name:IN HOME PODIATRY CLINIC LLC
Entity Type:Organization
Organization Name:IN HOME PODIATRY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITHCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-893-0500
Mailing Address - Street 1:1301 W 7TH ST
Mailing Address - Street 2:STE 121A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-2651
Mailing Address - Country:US
Mailing Address - Phone:817-348-9967
Mailing Address - Fax:877-474-7346
Practice Address - Street 1:1301 W 7TH ST
Practice Address - Street 2:STE 121A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2651
Practice Address - Country:US
Practice Address - Phone:817-348-9967
Practice Address - Fax:877-474-7346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty