Provider Demographics
NPI:1366078842
Name:SOLE PURPOSE PODIATRY, LLC
Entity type:Organization
Organization Name:SOLE PURPOSE PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FANTA
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:MORGAN-KITSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:302-538-0575
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-0813
Mailing Address - Country:US
Mailing Address - Phone:302-526-9582
Mailing Address - Fax:
Practice Address - Street 1:8900 COLUMBIA 100 PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2336
Practice Address - Country:US
Practice Address - Phone:302-526-9582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty