Provider Demographics
NPI:1770393886
Name:THE FOOT BULLY LLC
Entity type:Organization
Organization Name:THE FOOT BULLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVINESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-355-1550
Mailing Address - Street 1:13531 WILL CLAYTON PKWY
Mailing Address - Street 2:STE 300 PMB 1128
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346
Mailing Address - Country:US
Mailing Address - Phone:346-355-1550
Mailing Address - Fax:346-331-4620
Practice Address - Street 1:11503 N SAM HOUSTON PKWY E STE H
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-4732
Practice Address - Country:US
Practice Address - Phone:832-875-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty