Provider Demographics
NPI:1962689042
Name:DELTA FOOT CLINICS, INC
Entity Type:Organization
Organization Name:DELTA FOOT CLINICS, INC
Other - Org Name:THE FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SHOCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-638-7520
Mailing Address - Street 1:1814 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3710
Mailing Address - Country:US
Mailing Address - Phone:601-638-7520
Mailing Address - Fax:601-638-7541
Practice Address - Street 1:1814 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3710
Practice Address - Country:US
Practice Address - Phone:601-638-7520
Practice Address - Fax:601-638-7541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80142261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4342670001OtherMEDOCARE DME
MS1851563OtherUNITED HEALTHCARE
MS00119033Medicaid
MS430434140AOtherBCBS
MS5963224OtherAETNA
LA1540447Medicaid
MS480026580OtherRAILROAD MEDICARE
MS412865OtherFIRST HEALTH
MS=========OtherSTATE EMPLOYEE GROUP BENE
MS430434140AOtherBCBS
MS4342670001OtherMEDOCARE DME
MS00119033Medicaid
LA1540447Medicaid
MS480026580OtherRAILROAD MEDICARE
MS=========OtherGEHA
MS=========OtherMS PUBLIC ENTITY EMPLOYEE
MS=========OtherSTATE EMPLOYEE GROUP BENE
MS4342670001Medicare NSC
MS480026580Medicare PIN
LA4J434CP38Medicare PIN
MS=========OtherMAILHANDLERS
LAU68247Medicare UPIN