Provider Demographics
NPI:1871046763
Name:FOOT CLINIC OF GRETNA ,LLC.
Entity Type:Organization
Organization Name:FOOT CLINIC OF GRETNA ,LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINH
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:504-227-2749
Mailing Address - Street 1:2209 N VILLAGE GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-7020
Mailing Address - Country:US
Mailing Address - Phone:504-227-2749
Mailing Address - Fax:504-263-1900
Practice Address - Street 1:775 BEHRMAN HWY
Practice Address - Street 2:SUITE B
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-3011
Practice Address - Country:US
Practice Address - Phone:504-227-2749
Practice Address - Fax:504-263-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD218R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541621Medicaid
LA5A560Medicare PIN