Provider Demographics
NPI:1407025935
Name:ADULT AND PEDIATRIC FOOT CENTER, LLC
Entity type:Organization
Organization Name:ADULT AND PEDIATRIC FOOT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:LAVALE
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:901-537-0078
Mailing Address - Street 1:5362 ESTATE OFFICE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3635
Mailing Address - Country:US
Mailing Address - Phone:901-537-0078
Mailing Address - Fax:901-537-0096
Practice Address - Street 1:5362 ESTATE OFFICE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3635
Practice Address - Country:US
Practice Address - Phone:901-537-0078
Practice Address - Fax:901-537-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4822210213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3353516Medicaid
TN5537170001Medicare NSC
TN3353517Medicare PIN