Provider Demographics
NPI:1952667305
Name:AGAPE FOOT & ANKLE CLINIC, LLC
Entity Type:Organization
Organization Name:AGAPE FOOT & ANKLE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORLISS
Authorized Official - Middle Name:LA-SHUNUETTE
Authorized Official - Last Name:AUSTIN-HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-483-9761
Mailing Address - Street 1:PO BOX 543
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30298-0543
Mailing Address - Country:US
Mailing Address - Phone:404-483-9761
Mailing Address - Fax:
Practice Address - Street 1:3693 WITTENBURG CT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5507
Practice Address - Country:US
Practice Address - Phone:404-483-9761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000689213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU41116Medicare UPIN