Provider Demographics
NPI:1871323683
Name:MODERN PODIATRY, LLC
Entity type:Organization
Organization Name:MODERN PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIBIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:WANZU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:470-781-5585
Mailing Address - Street 1:1825 HIGHWAY 34 E STE 3410
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6433
Mailing Address - Country:US
Mailing Address - Phone:770-251-8940
Mailing Address - Fax:770-251-5685
Practice Address - Street 1:1825 HIGHWAY 34 E STE 3410
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6433
Practice Address - Country:US
Practice Address - Phone:770-251-8940
Practice Address - Fax:770-251-5685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric