Provider Demographics
NPI:1447276639
Name:FOOTLOGIC, INC.
Entity type:Organization
Organization Name:FOOTLOGIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIGGEN
Authorized Official - Suffix:II
Authorized Official - Credentials:BOCO, CO
Authorized Official - Phone:828-697-0048
Mailing Address - Street 1:107 E WALKER ST
Mailing Address - Street 2:
Mailing Address - City:EAST FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28726-2235
Mailing Address - Country:US
Mailing Address - Phone:828-697-0048
Mailing Address - Fax:828-698-6882
Practice Address - Street 1:107 E WALKER ST
Practice Address - Street 2:
Practice Address - City:EAST FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28726-2235
Practice Address - Country:US
Practice Address - Phone:828-697-0048
Practice Address - Fax:828-698-6882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1291920001Medicare NSC