Provider Demographics
NPI:1871524595
Name:CHARLOTTE FOOT CLINIC
Entity type:Organization
Organization Name:CHARLOTTE FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MOA INSURANCE PROCESSOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TROUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MOA
Authorized Official - Phone:704-394-4980
Mailing Address - Street 1:4016 WILKINSON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208
Mailing Address - Country:US
Mailing Address - Phone:704-394-4980
Mailing Address - Fax:704-392-8962
Practice Address - Street 1:4016 WILKINSON BLVD
Practice Address - Street 2:STE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208
Practice Address - Country:US
Practice Address - Phone:704-394-4980
Practice Address - Fax:704-392-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
012EJOtherBCBS