Provider Demographics
NPI:1770670416
Name:TLC PODIATRY, P.C.
Entity Type:Organization
Organization Name:TLC PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ARLENE
Authorized Official - Last Name:VIA-BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:912-285-0069
Mailing Address - Street 1:605 MARY ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3726
Mailing Address - Country:US
Mailing Address - Phone:912-285-0069
Mailing Address - Fax:
Practice Address - Street 1:605 MARY ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3726
Practice Address - Country:US
Practice Address - Phone:912-285-0069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000743213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00623334BMedicaid
GACJ5590Medicare ID - Type UnspecifiedGEORGIA RAILROAD MEDICARE
GA00623334BMedicaid