Provider Demographics
NPI:1134568124
Name:CHATEAU FOOT AND ANKLE CENTER, LLC
Entity type:Organization
Organization Name:CHATEAU FOOT AND ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CASTELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-648-5040
Mailing Address - Street 1:1515 RIVER PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-5602
Mailing Address - Country:US
Mailing Address - Phone:770-648-5040
Mailing Address - Fax:
Practice Address - Street 1:1515 RIVER PL
Practice Address - Street 2:SUITE 140
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5602
Practice Address - Country:US
Practice Address - Phone:770-648-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-23
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000569213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT92374Medicare UPIN