Provider Demographics
NPI:1730346941
Name:ALLSTAR FOOT CARE CENTER LLC
Entity type:Organization
Organization Name:ALLSTAR FOOT CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENEDICTO
Authorized Official - Middle Name:V
Authorized Official - Last Name:BITUIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-693-3914
Mailing Address - Street 1:PO BOX 1065
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-1065
Mailing Address - Country:US
Mailing Address - Phone:404-693-3914
Mailing Address - Fax:
Practice Address - Street 1:285 BOULEVARD NE
Practice Address - Street 2:SUITE 140
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4205
Practice Address - Country:US
Practice Address - Phone:404-265-1044
Practice Address - Fax:404-265-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000819213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00783956BMedicaid
GAU69480Medicare UPIN