Provider Demographics
NPI:1679849806
Name:FLORENCE PODIATRY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FLORENCE PODIATRY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-679-9090
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:492 W CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4447
Practice Address - Country:US
Practice Address - Phone:843-679-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORENCE PODIATRY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site