Provider Demographics
NPI:1912176546
Name:CENTERVILLE FOOT CARE, P.C.
Entity Type:Organization
Organization Name:CENTERVILLE FOOT CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-985-6879
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0846
Mailing Address - Country:US
Mailing Address - Phone:770-985-6879
Mailing Address - Fax:770-985-6894
Practice Address - Street 1:148 MISSION OAK DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4153
Practice Address - Country:US
Practice Address - Phone:770-985-6879
Practice Address - Fax:770-985-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1002910001Medicare NSC