Provider Demographics
NPI:1083854517
Name:FOOT CENTERS OF NC, PA
Entity type:Organization
Organization Name:FOOT CENTERS OF NC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-200-8588
Mailing Address - Street 1:76764 LANCELOT CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-7103
Mailing Address - Country:US
Mailing Address - Phone:760-200-8588
Mailing Address - Fax:760-345-3609
Practice Address - Street 1:5921 W FRIENDLY AVE STE D
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-3268
Practice Address - Country:US
Practice Address - Phone:336-218-8490
Practice Address - Fax:336-768-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC409213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty