Provider Demographics
NPI:1750822565
Name:FARAGALLA FOOT CARE LLC
Entity Type:Organization
Organization Name:FARAGALLA FOOT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:DR
Authorized Official - First Name:WASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAGALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-655-4146
Mailing Address - Street 1:11416 GRAMERCY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-8459
Mailing Address - Country:US
Mailing Address - Phone:551-655-4146
Mailing Address - Fax:
Practice Address - Street 1:2105 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1640
Practice Address - Country:US
Practice Address - Phone:551-655-4146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3803213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty