Provider Demographics
NPI:1154536126
Name:SOUTH FULTON FAMILY FOOT CARE, INC.
Entity type:Organization
Organization Name:SOUTH FULTON FAMILY FOOT CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONA
Authorized Official - Middle Name:RENELL
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-964-2201
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0188
Mailing Address - Country:US
Mailing Address - Phone:770-964-2201
Mailing Address - Fax:770-306-9744
Practice Address - Street 1:67 W CAMPBELLTON ST
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-1338
Practice Address - Country:US
Practice Address - Phone:770-964-2201
Practice Address - Fax:770-306-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA697261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4355747OtherGA AETNA PPO NUMBER
GA451998OtherGA BCBS NUMBER
GA697OtherGA STATE LICENSE NUMBER
GA4355747OtherGA AETNA PPO NUMBER
GA=========OtherGA TAX ID NUMBER
GA48SCBKSMedicare PIN