Provider Demographics
NPI:1912218504
Name:FOOT CARE STORE INC
Entity Type:Organization
Organization Name:FOOT CARE STORE INC
Other - Org Name:DIA-FOOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-721-7063
Mailing Address - Street 1:3281 FAIRLANE FARMS RD STE 7
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6503
Mailing Address - Country:US
Mailing Address - Phone:561-791-1213
Mailing Address - Fax:561-791-9919
Practice Address - Street 1:3281 FAIRLANE FARMS RD STE 7
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6503
Practice Address - Country:US
Practice Address - Phone:561-791-1213
Practice Address - Fax:561-791-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1985335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003177356AMedicaid
VA1740333061Medicaid
FL029761501Medicaid
FL0008364940OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS,PROSTHETICS & PEDORTHICS, INC.
FL0008364940OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS,PROSTHETICS & PEDORTHICS, INC.