Provider Demographics
NPI:1952814717
Name:PRIMARY FOOT CARE, LLC
Entity Type:Organization
Organization Name:PRIMARY FOOT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:MONICA
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:888-499-7747
Mailing Address - Street 1:9160 ESTATE THOMAS
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802-3641
Mailing Address - Country:US
Mailing Address - Phone:888-499-7747
Mailing Address - Fax:
Practice Address - Street 1:3004 ESTATE ALTONA
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-5735
Practice Address - Country:US
Practice Address - Phone:888-499-7747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1475261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI1952814717OtherVI EQUICARE
DC011589800Medicaid