Provider Demographics
NPI:1659447878
Name:CANTON FOOT CLINIC
Entity Type:Organization
Organization Name:CANTON FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:F
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:CNS
Authorized Official - Phone:601-672-7835
Mailing Address - Street 1:PO BOX 720894
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-0894
Mailing Address - Country:US
Mailing Address - Phone:601-672-7835
Mailing Address - Fax:601-346-7133
Practice Address - Street 1:205 RIDGE PARK CV N
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-9679
Practice Address - Country:US
Practice Address - Phone:601-672-7835
Practice Address - Fax:601-346-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR772161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125897Medicaid
MS04587370Medicaid
C03380OtherMEDICARE GROUP
MS00125897Medicaid
C03380OtherMEDICARE GROUP
MSP58403Medicare UPIN