Provider Demographics
NPI:1548662935
Name:PERSONAL FOOT CARE II, LLC
Entity type:Organization
Organization Name:PERSONAL FOOT CARE II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:804-732-1211
Mailing Address - Street 1:2020 WAKEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2112
Mailing Address - Country:US
Mailing Address - Phone:804-732-1211
Mailing Address - Fax:804-733-5946
Practice Address - Street 1:2020 WAKEFIELD AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2112
Practice Address - Country:US
Practice Address - Phone:804-732-1211
Practice Address - Fax:804-733-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301109213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty