Provider Demographics
NPI:1760538995
Name:ANKLE AND FOOT CENTER OF GEORGIA, LLC
Entity Type:Organization
Organization Name:ANKLE AND FOOT CENTER OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HOLLSTROM,JR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-838-4151
Mailing Address - Street 1:1555 DOCTORS DR
Mailing Address - Street 2:STE 106
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4132
Mailing Address - Country:US
Mailing Address - Phone:706-845-9370
Mailing Address - Fax:706-845-9371
Practice Address - Street 1:104 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4460
Practice Address - Country:US
Practice Address - Phone:770-838-4151
Practice Address - Fax:770-838-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherEIN