Provider Demographics
NPI:1013239615
Name:ADVANCE FOOT CENTER
Entity Type:Organization
Organization Name:ADVANCE FOOT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN-KHOA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-265-1595
Mailing Address - Street 1:1327 E. PIONEER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010
Mailing Address - Country:US
Mailing Address - Phone:817-265-1595
Mailing Address - Fax:817-701-1742
Practice Address - Street 1:2909 S. HAMPTON ROAD
Practice Address - Street 2:SUITE 122
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224
Practice Address - Country:US
Practice Address - Phone:877-482-6407
Practice Address - Fax:817-701-1742
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCE FOOT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDP1396261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0927402-01Medicaid
TX0927402-01Medicaid