Provider Demographics
NPI:1972856029
Name:ADVANCED REGIONAL FOOT CLINIC PLLC
Entity Type:Organization
Organization Name:ADVANCED REGIONAL FOOT CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BHEKUMUZI
Authorized Official - Middle Name:M
Authorized Official - Last Name:KHUMALO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:731-885-7834
Mailing Address - Street 1:1720 E REELFOOT AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-6047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 E REELFOOT AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-6047
Practice Address - Country:US
Practice Address - Phone:731-885-7834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty