Provider Demographics
NPI:1831306711
Name:CAROLINA FAMILY FOOT CARE PC
Entity Type:Organization
Organization Name:CAROLINA FAMILY FOOT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MIKETA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-557-5148
Mailing Address - Street 1:122 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1933
Mailing Address - Country:US
Mailing Address - Phone:919-557-5148
Mailing Address - Fax:
Practice Address - Street 1:122 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1933
Practice Address - Country:US
Practice Address - Phone:919-557-5148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909182Medicaid
NC0812420003Medicare NSC
NC2433035Medicare PIN
NC5909182Medicaid