Provider Demographics
NPI:1699382879
Name:ROANOKE FOOT & ANKLE INSTITUTE, PLLC
Entity Type:Organization
Organization Name:ROANOKE FOOT & ANKLE INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:415-602-2048
Mailing Address - Street 1:1224 N HIGHWAY 377 # 303-151
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9103
Mailing Address - Country:US
Mailing Address - Phone:817-674-7494
Mailing Address - Fax:
Practice Address - Street 1:1713 S FM 51 STE 103
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3644
Practice Address - Country:US
Practice Address - Phone:940-627-0993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROANOKE FOOT & ANKLE INSTITUTE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty