Provider Demographics
NPI:1710999792
Name:GENTLE FOOTCARE LLC
Entity Type:Organization
Organization Name:GENTLE FOOTCARE LLC
Other - Org Name:GENTLE FOOT CARE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-239-9444
Mailing Address - Street 1:3255 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-1923
Mailing Address - Country:US
Mailing Address - Phone:614-239-9444
Mailing Address - Fax:614-239-1080
Practice Address - Street 1:3255 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-1923
Practice Address - Country:US
Practice Address - Phone:614-239-9444
Practice Address - Fax:614-239-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2194209Medicaid
OH2194209Medicaid