Provider Demographics
NPI:1972043057
Name:DIRECT FOOT CLINIC LLC
Entity Type:Organization
Organization Name:DIRECT FOOT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-541-8734
Mailing Address - Street 1:121 HICKORY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8059
Mailing Address - Country:US
Mailing Address - Phone:813-541-8734
Mailing Address - Fax:
Practice Address - Street 1:5535 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-7332
Practice Address - Country:US
Practice Address - Phone:813-574-4869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty