Provider Demographics
NPI:1750792867
Name:GR VITO-BROOKDALE FOOT CLINIC
Entity type:Organization
Organization Name:GR VITO-BROOKDALE FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-618-6961
Mailing Address - Street 1:PO BOX 24561
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4561
Mailing Address - Country:US
Mailing Address - Phone:336-618-6961
Mailing Address - Fax:
Practice Address - Street 1:533 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:336-618-6961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC330213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty