Provider Demographics
NPI:1124101373
Name:FOOTHEALS PROSTHETICS AND ORTHOTICS, INC.
Entity type:Organization
Organization Name:FOOTHEALS PROSTHETICS AND ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROTHETIST, ORTHOTIST,, PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:CP, BOCO, CPED
Authorized Official - Phone:423-975-5462
Mailing Address - Street 1:2406 SUSANNAH ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1725
Mailing Address - Country:US
Mailing Address - Phone:423-975-5462
Mailing Address - Fax:423-975-5463
Practice Address - Street 1:2406 SUSANNAH ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1725
Practice Address - Country:US
Practice Address - Phone:423-975-5462
Practice Address - Fax:423-975-5463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4145147OtherBCBS OF TN
TN1455141Medicaid
TN1455141Medicaid