Provider Demographics
NPI:1699015867
Name:WALLINGTON FOOTCARE CENTER, INC.
Entity Type:Organization
Organization Name:WALLINGTON FOOTCARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIETLINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-458-8090
Mailing Address - Street 1:905 ALLWOOD RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1945
Mailing Address - Country:US
Mailing Address - Phone:973-458-8090
Mailing Address - Fax:973-458-8091
Practice Address - Street 1:905 ALLWOOD RD STE 206
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1946
Practice Address - Country:US
Practice Address - Phone:973-458-8090
Practice Address - Fax:973-458-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00251800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4108140001Medicare NSC