Provider Demographics
NPI:1891939682
Name:GENTLE FOOT CARE OF WESTERN OHIO, INC.
Entity Type:Organization
Organization Name:GENTLE FOOT CARE OF WESTERN OHIO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-457-3212
Mailing Address - Street 1:3800 WOODWARD AVE STE 318
Mailing Address - Street 2:SUITE 1102
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2066
Mailing Address - Country:US
Mailing Address - Phone:313-833-3090
Mailing Address - Fax:313-833-7843
Practice Address - Street 1:3800 WOODWARD AVE STE 318
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2066
Practice Address - Country:US
Practice Address - Phone:313-833-3090
Practice Address - Fax:313-833-7843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENTLE FOOT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002275261QP1100X, 332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316191679OtherMEDICARE NPI
MIMI1225OtherMEDICARE PTAN
MIMI1225001OtherMEDICARE PTAN
MI1316191679Medicaid
MI1417136029OtherMEDICARE NPI
MI1417136029Medicaid
MI6216330001Medicare NSC