Provider Demographics
NPI:1194296087
Name:FOOTSTEPS, LLC
Entity type:Organization
Organization Name:FOOTSTEPS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:B
Authorized Official - Last Name:FORMANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-756-0034
Mailing Address - Street 1:6141 PARKFOREST DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6111
Mailing Address - Country:US
Mailing Address - Phone:225-756-0034
Mailing Address - Fax:225-756-0708
Practice Address - Street 1:826 W HIGHWAY 30 STE A
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4852
Practice Address - Country:US
Practice Address - Phone:225-803-1516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1173576Medicaid