Provider Demographics
NPI:1215205992
Name:MT. HOLLY FAMILY FOOTCARE
Entity type:Organization
Organization Name:MT. HOLLY FAMILY FOOTCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SPIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-261-2223
Mailing Address - Street 1:1561 ROUTE 38 STE 4
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-2939
Mailing Address - Country:US
Mailing Address - Phone:609-261-2223
Mailing Address - Fax:609-702-1111
Practice Address - Street 1:1561 ROUTE 38 STE 4
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-2939
Practice Address - Country:US
Practice Address - Phone:609-261-2223
Practice Address - Fax:609-702-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD002658213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5470307Medicaid